HomeMy WebLinkAbout0424 OLD TOWN ROAD Ufa y Old
. . Barnstable
•Perffiit o1.�Z �
Town Of B
} Regulatory Services Fee
s 110mas F.Geller,Director
Bu Rding lHvi,siOn
Tom Perry,CB4, Btsilftg Commissioner
TOWN OF BA�i RE 200Msiu shunt,xyamis,MA 02601
warvr.tflwa.barnstsblA.ma.us Fax: 509-790-62.30
Offioe; 50g-862-4038 , A O SENT ONLY
r Not valid W*Md Red x.�INPW
Mala/percat Number�• l --
ptop"Addrem
�]/'limideatial Vaho of Wade fel Minimum fee of 535.00 for work wider$6000.00
Owner's Name dt AddeeMs ... �d7
Cotrtractor'gName�. ,C 'u�/�? "`' _ Telephone Number
Home Improvement Contractor License#Of applicable) /l�/1 �/��
Coosttncdon$WWVWr's Licem#(if applicable)
❑W'otlnwls Compensation Insurance
Check ow:
I ani a sole proprieW
Lam the Homeowner ,
bave'9VO*Ws compwiadon Insurance
Name
Iaaureaoe Compmy
Worimnso's Comp.Policy#
Copy orjunrlm Compliance Certificate must accompany each permit:
Permit te%(cite&box)
/knomof(barritsne wailed)(strippleg old shh8 ) All won debris will be taken to �i'y.P Z)tJ%7y
❑Re-roof(hnrricano nailed)(not stripping• Going over wi tiug laym of root) .
e #of do=
® ReplacemaW WindovaWdooWsiidw&U-Value (msxemutan 35)#of windows
_ a
❑ SMob/CoboU M0A=W@ detectors 4 Boor plans marked with red S and Wspeetlons required.
Separate lflsatrleal da Fire Permits req=h%&
+VUltace tt�gttired; luYaste Of tlsEB POe duos etot ammpt with otimr tows de�p�tmot t�aieiim,i a Fiitfatiq Co:ss�vatfnn,etc•
e*+Nobs: Property ownat must sign Property Owner Letter of Permission.
A OW or the Home Loprovement Contractors Ucause&Construction Supervisors License is
fired.
SIGNATURE:
• �C
-- 'offa�na,w v l//c'oCc�/la��uar/n�all� Lloause or relistradoa valid for individul ues only
.0mee of Camew Agra&BoWe"geguktiou before the expiration date. U found return to:
iMS i ONNEMEM CONTRACTOR Of a of Goasntrwr Affi ks and BuAnm Reguistion
to l't
mom g Private Conmrstior ton MA A -Suite S170
0
Boston, o2116
DWD COX,IW-.
David Cox
16 IAVEfyOEft LN �•a�- _ ...___
W.YARmourH,AAA 02673 Undemcretsry Net valid wwwat signature
,I
Massachusetts -Department of Public Safety
Board of Building Reguiations and Standards
Camtruction Supervisor
License:C$.Od383y
DAVI D R COX ,
"k°
PO BOX 401 i.
South Yscmouth KA
Xxoiration
1a1i>i1�01b
Commissioner
�' a4nitalA►uts, �
HAMM
H, Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200.Main Straet,'Hyannis,MA 02601
• www.town.barnstable.ma.as '
Office: 508-962-4038 Fax: 508-790-6230
Property ljwnet Must
Complete and Sign This Section
If Using A Builder ,
'J/A eQl a�lv ; as Owner of the subject'property
hereby authosize to act on' my behal f
iu all matters relative to work author4ed by this building permit application for.
(Address of job)
Ssgnsture o ._.�._.� ._ Date
rJ
Past Nsme _
If Property Owner Is applying for permit,please.complete the Homeowners License Exemption Form on,the
reverse side.
Tke Comfator:wealth of 3:fasacr .;erts
4 Department of Lnduslria111ccidz,at�
�` PDX of Investigations
600 At'ashingtoa Sfreef
Boston,M.4 02111
www.mass:gov/dia
Workers' Compensation Insurance Affidavit: Build ers/Contras:tors/Eieetriciaas/P lamb ers
ARRUtant formation
Please riot Le�ibiv
Name (Business/Ortan}zasicn/Individus!):
Address: /4v /•p���,�.�n�� ��
City/State/Zip; 1,�,�JJ,dp, �9� �,��� Y Phoae#:
Are ou an employer? Check the appropriate box; ----
I,Are
am a employer with ,� 4. ❑ 1 am a genera!contractor and 1F7. [D
f project(required):
employees(full and/or part-time).* have hired the sub.contractorsNow constmc�tan
2.® 1 am a sole propridtor or partner- fisted on the attached sheet Remodeling
ship sad liave•ao employees These sub-contractors have Demolition
wo for the '
rldng to any ca act workers
P h' comp,insurance.[No workers' comp, insurance 5. ❑ We are a corporation and its Bnllding addition
r aired,
3,❑ e9 ] officers have exercised their 1017 Blsctrleal repairs or additions
I ttm a hotneawner doing all work right of exetnptioA per MCL. 11.0 Plumbing repairs to additiors
thyself, (No workers'comp. c. 152,§l(4),'and we have no
ittsareaoe required.]t' erapioyees.[Novo&-t& I2.❑Raafrepai:s
comp.hisaraaee requirsd,j I3.0 Other
"Any Applicant that eheskt box tf i M=atso fill out the aeetion below sh
Om owing fhec watSoeu'oompenta6oa pofior intotmadoa
t 1� tlplvnen o ttuboilt this affidavit tadi=ft shay w doing ail wort;and then tore wbide wntmotm rnuat tubroit a ncvr a$daatt in6tcetistg such.
=Coetnetcos tlltt ebeele this box mutt attached an additional sheaf Agwin6 the aamc dt>,e sab.soutreceats and their wtu�errI camp, oli p P cy infoMation.
,ram an employer A&lsprovid6vy worker'corrrpenrallorr tnswaneeformy ertwloye:r Below 4F thepoliey andJob site
try formcllon.
Iasnraaee Company Name:_
Polisty M or Self-ins.Lie.M�� QJ�k 2?�/�y Expiration Date; 7�
,tab Site Address:__ /J y �� -- City/5tate/Zip:
At
tach a copy of the workers' s:otnpensatiOn policy declaration page(showing the policy number and expiration date).
Failure to secure covtxage as required under Section 25A ofMOL c. 152 can lead to the.imposition of criminal penalties of e
fine cp to S 1,500.00 and/or one-year imprisoiurteat,as well as civil penalties in the form of a STOP WORK ORDEZ 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 tht:Office of
investigation of the DIA for insurance coverage verificWon.
I do kereby cero un er thepabu andpenaltter ofperjrcry that the Information groNlded above tr trot and carreeL
t
ate: /7'1�'
Eco
ony. Do not write in thts area, to betompleted by C4 or town gfflcW
r Towns PermitlLicenseg AuULorlty(circle ome);
ed o±Flealt8 2, BulldiugDepartoheat 3.City/TowuClerk4.ZICCtrical Inspector 5.PlumbinglZupector
erct Person: Phone M
p.• �r..r� DAV110-2 OP ID:KG
' CERTIFICATE OF LIABILITY INSURANCE D1TE pW0D1YVYYi
07/22/21D14
THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CrKTIFICAT! GOES 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 INSURERISI, AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT'. If the certificate holder Is an ADDITIONAL INSURED,the policy(tes)must be endorsed. If SUBROGATION IS WAIVED,subject to
the farms and conditions of the policy,certain policies may require an endorsement. A statement or.this certificate does not confer rights to the
owfillcate holder In lieu of such endorsements. COWACT
PROOMR NME:
Northwood Ins,A�onc ,Inc. —`—�I "
640 Main Street,Svutte a 808•TT1.1632 508�93.29LYi
Hyannis,MA 02601 „OS:
0B1J AFFOFONO Caw_4wE — NAIC a
INsuRCRA:Tr9VOIOrs Insurance Coin pany
rain David Cox, Inc. INSURNR8:
P.O.Box401 WaURERC:
$Yarmouth,MA 02664 KRUKRD: t—
INSURERS: YV
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER.,
THIS 13 TO CERTIFY THAT THE POLiCIIE:S OF IN3URA.NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME:ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY RECUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHIct, TEAS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICAES DESCRIBEC HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _
TYPE OF INaNMKX POLICY NUMBER to M LIMn R
A CONOMCIAL GENERAL LIABILITY I EACH S 1,DOO,
CCU 880146Y7> 91 00,CLAIN7rM.40E 3 00
X Sualnese Owners I rMED EKP(Any me mfson; is
Call
_I I PERSONAL S AGJ IWAJ 7 I - 1,000.000
fiEN'I.A4GRF:�p E.INt-4Ppll?S Pf:R• I I � Gr-EN—ERa—L AGGREGATE 5_.__ Z,000,
POLL` j fT LQC PPI .ODUCTS•CGM�ir�P dpv £ 2,�,
OTHER. �79,
�owinmLAMUry I v J yV. L r. 5
+, E�d 6,tudenp
ANY AV-) 50DI_!IN.URY lPsr pwson} V_w
ALL OWNED I `xC i!DULAL'c ! + SIX4_'t?SJJPY(Dar c:fdantt
AUTOS AU'G_ 7_ _
NON.CWNED Y A —' c
HIRED Ai.TUB A4rre)5 I I Par
I I 5
um"Ad"LNY
ExemLUs CLAUAS IAAD° i I I I A0GRE5ATE 3
I D ' =-' 02
AND IMPLOYIN'LIAdtLITY I 3TA?UTE i R
A AhwPftUPeT13TORFARTNERELv^UTlvE Yt f OERTMIaAFOLLOW FROM CO 07AS/2014 I07J18/2015,EL.EA.cr ACCIDENT
RtYtIYB'R EX« NIA!
IT
.UUECYI N I A! f ----" I .--�--— •—
Of ICE
j� IV Y pwI HIN S DAYS I` f E s_CASEASE•'A Emw of EE s 100,
I�(1hr.
D 1;('P ZTt 0. F OmAnONS Wlcw I1 i E L.Di^EASE•POLIO LIMIT 3
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ONCRPTICN OF OPERAT101N91 LOCATIONe i ANCLie (ACORD101,Addkttanal Remarks Uh*Ws,may be atteehed IF mare apace in required)
CER T )LIDER CANCELLATION
TOWNSIAR
eNOULD ANY OF INS ABOVE OESgtIlSp POLiCIttW 09 CANCELLED®EFORE
THS 1XPIRATION DAIS TMSRSOP, NOIICE WILL tit! tHLIVERED IN
Town of Barnstable ACCORDANCE WITH 714E POLICY PROVISION',
230 Maln street
Kprinis,MA 02001 AWHORlMRGP"SENTATIVII
011981111•2014 ACORD CORPORATION. All rights reserved.
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