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HomeMy WebLinkAbout0588 OLD STRAWBERRY HILL ROAD OR Application number!'✓. s�U a► Fee ............. ..................................................... i1 iNSTABLL ' MAM $ Building Inspectors Initials... .. ...................... Date Issued.... I.....30 0� A6 ................................................. Map/Parcel.....�.�3 `/�r TOWN OF BARNSTABLE- IJUILDING KEPT. EXPEDITED PERMIT APPLICATION: APR 10 2020 ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZ ON PROPERTY INFORMATION - NSTAB Address of Project: 5 01J �� �� ►11 Ya , NUMBER Nq STREET VIL�AGE�� ��� _ � _ _ , Owner's Name: oS-,, 1"6 e0tt, Phone Number , 66 t 7/ ,l 1A Email Address: Cell Phone Number Project cost$ Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize ���► �J�1s jIC to make applicationr building permit in accordance with 780 CMR Owner Signa Date:!LIl O > TYPE OF WORK ED Siding 0 Windows (no header change) # F-1 Insulation/Weatherization F Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than I la eLAf shinFY44-hl l Construction Debris will be going t h 1,,�11&1111411 CONTRACTOR'S INFORMATION Contractor's e , Home Improvement Contractors Registration if applicable)# (attach copy) Construction Supervisor's License#CS` DJ D 1 (attach copy) Email of Contractor D3�� l Y�So h ye,o)'1') Phone number('5 30/ -G 1�3- ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE S BJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER *For Tents Only* Date Tent(s) will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. . Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signatur Date All permit applications are subject to a building official's approval prior to issuance. f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Legibly Name(Business/Organization/Individual Address: /'1 S�6' )l I'+ g City/State/Zip JtAIiLh 3 Phone#: ol) Are you an employer?Checkthe appropriate box: Type of project(required): 1. I am a employer with `1 4. I 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 ship and have no employees These sub-contractors have g. 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 11. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL (!n Roof 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 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name ilrlilzd Lt�uwz co Policy#or Self-ins.Lic.#:k1r,6 450 1 I U, t) Expiration Date:a - Job Site Address: g of a f� City/State/Zip (1 � 4 �,3� 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 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 for insurance coverage verification. I do hereby nder the pains and penalties of perjury that the information provided above is true and correct Si a Date: Phone# J " Official use only. Do not write in this area,to be completed by city 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#: 71 Client#:38860 2EXCELBU ACORDTa CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) o3/10/2020 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 have ADDITIONAL INSURED provisions or 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: The Hilb Group of N.E.dba PHONE 508 775-1620 FAX 5087781218 A/C No Ext: A/C No Dowling&O'Neil Insurance Agy E-MAIL P.O.Box 1990 ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORDING COVERAGE NAIC a INSURER A:NGM Insurance Company 14788 INSURED Excel Building Systems Company,Inc INSURER B:Associated Employers Insurance Company 11104 PO Box 436 INSURER C: Forestdale,MA 02644 INSURER D: 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 ADDL UBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER M/D MA) LIMITS A X COMMERCIAL GENERAL LIABILITY X X MP02774T 2/22/2020 02/22/2021 EACH OCCURRENCE $1 000 000 CLAIMS-MADE ❑X OCCUR PREMISESOEaEr ence $5OO OOO MED EXP(Anyone person) $10 000 PERSONAL&ADV INJURY $1,0009000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,1I00,000 PRO- POLICY I XI JECT I X I LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY M102774T 2/09/2019 .12/09/202 EDacccidentSINGLE LIMIT $1,600,000 ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY - AUTOS X WIRED ONLY X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY Per acdden[ UMBRELLA LIAR H OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE - AGGREGATE $ DED. RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY WCC5OO5O098182O2OA 3/05/2020 03/05/2021 X PER OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT s500 OOO OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $5OO O00 If yes,describe under DESCRIPTION OF OPERATIONS below I I I E.L.DISEASE-POLICY DMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE -THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 2 The ACORD name and logo are registered marks of ACORD #S256021/M256020 LS1 Commonwealth of Massachusetts ® Division of Prb eSsiohal Licensure T :. Buftding Regulations and:Standards ConstratctfQtrSiSpQrviso pes 0CS 098849 E 0&2 2021 f2ENAT0$ILVA �� P O BOX 436PX EORESTDALE MAC 02644 <^ ftliM ; Commisswner 1/LC Gis�pii�fll ��Po✓ir�t!✓E��i Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for.; dividual use only TYPE C000ration before the expiration..,date; If fountl:return ta` Redistrafion Expiration Office of Consumer Affair and Business Regulafion_. 182094 05l25/2021 1000 Washington Stre uite 710; EXCEL BUILDING SXSTEMS COMPANY WC Boston,MA 02118 s � RENATO DA SILV affi 8 JAN SEBASTIAN>DR STE'_9 /ww R f� SANDWICH MA 02563 NOt Y811 OUt SlgfldtUfe.?. `.Undersecretary 21