HomeMy WebLinkAbout0079 OLD YARMOUTH ROAD 'xl midy,�,a�v:� �
� _ _ _ �
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Town of Barnstable *Permit#
�13 Expires 6 onths from.issue date
Regulatory Services Fee
saxrrsrAsLE,
MASS.
a
9cb r 1639, �,�' 4 ,� Thomas F.Geiler,Director
Building Division
D
Tom Perry,CBO, Building Commissioner >P'1
200 Main Street,Hyannis,MA 02601
www.town.baanstable.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
�5y
Property Address 1 � ��G % li
4,1
Residential Value of Work
?dd Minimum fee of$35.00 for work unde 6000.00
Owner's Name&Address
Contractor's Name aG(.Y7 G! elephone Number
Home Improvement Contractor License#(if applicable) /7 'el
Construction Supervisor's License#(if applicable) L D ! 3—Z 5� J
�Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
I have Worker's Compensation IZce
Insurance Company Name
Workman's Comp. Policy#___J�!l� �/
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
❑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
t .`
*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.
f
of the Home Improve nt Lontr for icense&Construction Supervisors License is
SIGNATURE:
14 V
C:\Users\decollik\AppData\Local\Microsoll\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc
Revised 072110
f
A C o® CERTIFICATE OF LIABILITY INSURANCE DATE(2013D/YYYY)
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 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 endorsement(s).
PRODUCER CONTACT
Marsh USA Inc. NAME:
100 North Tryon Street,Suite 3200 PHONE FAX
Charlotte,NC 28202 E-MAIL Ex A/C No
Attn:For questions contact:insurancerequest@lowes.com ADDRESS:
INSURERS AFFORDING COVERAGE NAIC#
47095-CASUA-ONLY-13-14 INSURER A:National Union Fire Ins Co Pittsburgh PA 19445
INSURED Lowe's Companies,Inc.and subsidiaries INSURER B:New Hampshire Insurance Company 23841
including Lowe's Home Centers,Inc. INSURER C:Illinois National Ins Co 23817
Mooresville,
Box 1000 Safe National Casualty Corp.Mooresville,NC 28115 INSURER D:Safety Y 15105
INSURER E: Steadfast Insurance Company 26387
INSURER F
COVERAGES CERTIFICATE NUMBER: ATL-002939185-20 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 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.
INSR ADDL SUER
R. TYPE OF INSURANCE POLICY NUMBER MMIDDY� POLICY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY Self Insured-See Below DA A O REN
PREMISES Ea occurrence $
CLAIMS-MADE OCCUR MED EXP(Any one person) $
PERSONAL a ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $
POLICY PRO- LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
A X Ea accident 5,000,000
ANY AUTO CA5196309(AOS) 04/01/2013 04/01/2014 BODILY INJURY(Per person) $
g ALL OWNED SCHEDULED CA5196310(MA) 04/01/2013 04/0112014
AUTOS AUTOS BODILY INJURY(Per accident) $
A HIRED AUTOS AUTOS NON-OWNED CA5196311(VA) 04/01/2013 04/01/2014 PROPERTY DAMAGE $
Per accident
I X UMBRELLA LtAB X OCCUR
E EACH OCCURRENCE $ 5,000,000
EXCESS LIAB CLAIMS-MADE IPR3792301-00 04/01/2011 04/01/2014 AGGREGATE $ 5,000.000
DEO RETENTION$
g WORKERS COMPENSATION
WC019359017 AOS,WC019359015 MN 04101/2013 04101/2014 X WC STATU- OTH- $C AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC019359016 WI 04/01/2013 04/01/2014
B OFFICER/MEMBER EXCLUDED? a N/A E.L.EACH ACCIDENT $ 2,000,000
(Mandatory In NH) WC019359018 AK,AZ 04/01/2013 04/01/2014 E.L.DISEASE-FA EMPLOYE $ 2,000,000
B DESC descrit)e under
RIPTION OF OPERATIONS below WC019359019 NH,VT 04/01/2013 04/01/2014
E.L.DISEASE-POLICY LIMIT $ 2,000,000
A Excess WC XWC6636189(AOS) 04/01/2013 04/01/2014 WC:Stat/EL-.$3mil;xs$2mil SIR
A Excess WC XWC6636190(FL) 04/01/2013 04/01/2014 WC:StaUEL:$3mil;xs$2mil SIR
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required)
Insured is self insured for General Liability for the period of 4/01/2013 to 4/01/2014.
Evidence of Coverage
CERTIFICATE HOLDER CANCELLATION
Companies,Inc.
and subsidiaries SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
and subsidiaries THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 1000 ACCORDANCE WITH THE POLICY PROVISIONS.
Mooresville,NC 28115
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Diana Bentley
s
ACORD CORPORATION. All rights reserved
ACORD 25(2010/05) '�Th ACORD name andl go are registered marks of ACORD °A
4-.
CONTRACT# 0 0 0 6 0 3
MASSACHUSETTS EXTERIOR SOL'UTION$INSTALLED$ALES,CONTRACT
INSTALLED SALES SPECIALIST NUMBER CUSTOMER
G��r�f Cg (ST�V v 7 la)77 C t N0/2e oe A0c�JC1 �' G
S705E ND. STREET ADDRESS STREET ADrDR S '
37 r (Ly�r
Fly i �r.�. Y flu f O/d /u,"';0 1# /
CITY - STATE ZIP - CITY STATE ZIP
(-7e V /t/Wr s IVA
TELEPHON k" - TELEPHONE ,.,
�oay
7 '- — �s�,- 3�1
DATE _ FE NELOW'S HO ME 8E8ENTERS,INC:S MA HIC NO 148688 x,� ` CASH F nNK Lcc CrRE GE
.This is only a quote for the merchandise and services ponied below This tiecdmes an agreement upon payment'Upon payment.the entire a graement,.includ ngthe sperafcalry completed pages of This 3 ^
document,the Terms and Conditio s included wrth this document and any oche addenda aril attachments he eta shall be to herein as ih�s
PLEASE READ ALL TERMSAND CONDITIONS ON THE REVERSE SIDE OF THIS PAGEAND FOLLOWING PAGES BEFORE SIGNING.L +':
INSTALLATION STREET ADDRESS r CITY y STATE ZIP'
,<(/s 7;��i/ .r%1�',r.7 f�o X D. �"� a%- : !-, � Q r' (/r Jth I S 1.a�4'/✓
tA.j t'.�A i� �/ 1f P-I �
sG: -Frt /�,--/Z,a/s rNsfi,d�l(r r'�CC)e�S /,'r;//��I!s• ; �T rI
/able o vv�fS, 'S;%}! r;eT/�l fj�'S( 0vc2
e A. i 1?2 6�4u
�a.oe ;41('01, ai /of/ bole1/l�ue{�lS 1/ehd rex 4- 6 e ez`;i T
Contract Total
Are permits required for this installation? kYes [ ]No 'applicable tax included ��
NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right.By signing this.Contract;Customer
acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure
from renovation activity to be performed in Customer's dwelling unit.
PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees the right to take photographs of all work performed at the Premises related to this
Contract,and irrevocably grants to Lowe's all right,title and interest in and to the photographs for use in all markets and media,worldwide,in perpetuity.
Customer authorizes Lowe's to copyright, use rand publish the photographs in print and/or electronically, and agrees that Lowe's may use such
photographs for any lawful purpose, including,but not limited to,marketing, advertising, publicity, illustration, training and Web content. By initialing
here,Customer agrees to the foregoing. t,/Zi [Customer to initial to the left].
Work is,-to commence u on reasonable availability of Contractor and/or any special order or customer a Good(s)which is anticipated to be
is,
`//—/ [fille in date].Estimated completion date is 7' �S_ [fill in date].
Said estimated substantial completion date is not of the a Bence. A statement of any contingencies that would materially change said estimated substantial
completion date is as follows:
(if applicable,inserta statment of such contingencies).
IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full.
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00:
[Customer to Pay in Full; OR ( ]Customer to use the following payment schedule:
(1)Deposit $ to be paid upon siging contract.Deposit should be 1/3 the total contract price;and
(2)Payment of$ to be paid anytime after this Contract is signed and before commencement of installation,I/We authorize Lowe's
to do one of the following(check appropriate box below):
( ]Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed;
or
( ]Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed;and
(3)Final payment of$100.00 to be paid upon completion of the installation and both parties'satisfaction.
NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L.c 142A
LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT
LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT-
IVE OFFICE OF CONSUMER AFFAIRS AND BUISNESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION
AS PROV BED INJ)d�a le.142A. _ /3
Y % Date:
Lowe' ome Centers,Inc
By:. ;"1 G` f Date:
Owner Signature
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED
BY LOWE'S PURSUANT TO M.G.L.c.142A.THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE
SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND
CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT.
BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERSTAND AND AGREE TO THE
TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS
CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF.SIGNATURE.
WITNESS OUR HAND(S)AND SEAL(S)BELOW THIS a DAY OF :I (j V oz 4/
Lowe's-Home Centers,Inc.
5 ecialist oiAbove Owner Co-owner or Witness
Customef acknowledges receipt of a true copy of this contract which was completely filled in prior to Customer's execution hereof.You,the buyer,may
cancet`(his transaction at any time prior to midnight of the third business day after the date of this transaction.See the attached notice of cancellation
form for an explanation of this right.
P11 P r:r1PV 0 2004 by Lowe a®Lowe's and the gable design
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
�4;r Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: ��
� J
01
City/State/Zip X/I ^ Phone M 2'
Are you an employer?Check the appropriate box:
general contractor and I Type of project(required):
1.❑ 4.I am a employer with I am a g
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
workingfor me in an capacity. employees and have workers'
y p � insurance.# 9. ❑Building addition
[No workers comp. insurance comp.
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 12.❑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 mist 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.
tContractors 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: /V��IJ 1`�llGii! it . �I SG�l�2Nce Ifi A041 v
Policy#or Self=ins. Lic.#: C (� 7j ?� ( � Expiration Dater _
Job Site Address: City/State/Zip: 1 `
Attach a copy of the workers' compensation policy declaration page(showing the policy nu ber 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA fo surance coverage verification.
I do hereby certify an a t' ur formation provided abovey true nd correct.
St nature: Date: I- fl
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
R
' � �1ie�oomrrro�uuealdi o��/ c%uaek2
Office o[Consamer Affairs&Business Regulation License or registration valid for individul use only
OME IMPROVWENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registration-'444-688 Type. 10 Park Plaza-Suite 5170
Expiral '""'` ` 13 d Boston MA 02116
Supplement C +
LOWE'S HOME:.
ROBERT ABBOT ;'=r; :
jas
136 TURNPIKE
SOUTH BOROUGH,;(tif "Q972 Undersecretary Not vafid withou ignat e
r
t
k.
..f,�us �fr,>urrRr:nurril/f r.�.:1'7.ri.a;arl�rrJc,/%: `: ;
-- Office of Consumer Affairs&Business Regulation ]License or o valid for individul use only
-,00dAE i1I1lPROVEdREAl7'CORRRACTOR
before the expi C late6 If found return to:
�e9istration: 16M27 Type:
Office of Cons n airs and Business Regulation
xpiration:... 12Tj/2014 DBA 10 Park Plaza-Boston,MA 0Z1 '' ; 170
KENNETH KENDALL
KENNETH KENDALL
5 WELDEN PL
FAIRHAVEN,BRA 02719 Undersecretary Not va out signature
and Standards '
COnst;uetion Supen isor
License: CS-076163
f'rti q
F�
KENNETH D"I" "-
Y.
5 WEEDEN PIAOO R
FAIRIUVEN bU ;
,t w Expiraildn
�OrimtSStflSIEr 01112(2015
g+
i
xi k
The Commonwealth of A,
fts
Department of Industrial Accides;
O IIce of Invesfigations , y
T
110 Washington S`freet
Boston,.4fA 02111 E
Workers, Compensation Insurance Aida I$ui d WW
e s/
A IaCant Informatiota ti_ f
Conf�aci`oa.'s/Flectricians/plumbers
3lile(Business) R Please Pant Le ib1
OrganizatioMndividual): v
Address:
CftY/State/Z1 t'.;E'
Are you
/ Phone
an employer?Check the appropriate box:
am a employer with '
employees — 4. ❑ 1 am a general contra Type off project(required):
2 (full and/or part-time). have hired the sub-contractors contractor and I
I am a sole proprietor or b•contractors ; 36' Q Alew construction
ship and have no employees
listed on the attached sheet t i 7.
workingThese sub-contractors have n Remodeling
for in an,
[No workers'comp •J capacity. workers'comp.insurance. s Q Demolition
required) Insurance 5. ❑ We are a corporation and its t
❑Building addition
3' ai am a homeowner doing all work officers have exercised their '
1 'myself
self. ri t `I Electrical rePairs or additions
Y [Nv workers gh o€exemption per MGL
L�sutance required.] comp' c. 152;.§1(4),and we have no 1'0 Plumbing repairs or additions
eq .red.)t em to
P yees.[No workers' Iri� roof repairs
� ioi eo,aPpt,cant that checdcs box#1 must �o 1P•insurance required s 13.Q Other
Hoineo vne �Ilo submit this agd o fill out the section below showingl
tCon'tractors that check this box m avrt indicating they are doing an work and the� �poi'cy infortnatiorc
at*Workers, r
attached an additional sheet showing the name at>hde contractors ..nFb a new�arrr an errrptoyer that isProvidu�g rcorkers'comp b'0ptj�ctors d1heu affddvit indicating such_
err,joPrna¢iora. ensatiori irrsrcrarece or ara x; ��•�i`y�'formatio�.
Insurance Corr _ � y��•���:�eloty as Elie policy attd job site
p�Y dame: 3 4 P
Policy#or Self-
ins.Lie.
Job Site Address: BxPhon date:
Attach a ^ City/ . 3 : �
copy of the workers'corrpeusation policy declaration page showing t ' .P
Failure to secure coverage as required under Section 25A of MGL c. 152 can I g he olii nu er grad e'A
fine up to$1,500.00 and/or one-year inprisonrnent,as well as civil penalties in gpxatioan s of
Of up to$250.00 a da against end f th r
Y gains•the violator. Be advised that a co Py�?1?osition of criminal penalties of a
Iarvesti ations of the fo o' STOP WORK ORDER and a f1h,
g he DIA for insurance coverage verification. Py of this statement ma be Forwarded to the O#I'nce of
p do hereby certif under the pants and penalties o er' i
t !
t`P Iury that the att fortpaatiou provt above Is true arad correct
Si $nnre: e0i
PhonevC,
®ffacial use 0111Y. f,
Do not Write in dais area to he cotrrp[eted by city or town o '
City,or Town: ffiCtal > i } li
Issuing Authori Permit/License
ty(circle one):'- Board of Health 2. Building Department 3,Cit,�IToF��ar Clerk ii
6. Other ' t !
4.Electrical inspector 5.Plumbing inspector - �K':
Contact } ' 'Persons t ;
oF��iti'
w 1AkNSTABLE, '
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office:.508-862-4038 : Fax: 508-790-6230-
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorise' [ - �r� ✓Z S a�i�L. �fi 1, to act on my behalf,
in•all matters reh<dve to work authorized by this building permit application for:
Ya 14412n�IiSIWX-06C)(
(Address of.Job)
0, 4
Signature o Owner Date
CV id, S 2
Print ame
If Property Owner is applying for permit, lease complete the Homeowners License Exemption Form on the
reverse side. P P
C:\Users\decollik\AppData\Local\Microsoft.\Wiiidows\Teinporary Inteniet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc.
Revised 012110