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HomeMy WebLinkAbout0023 PLEASANT PARK AVE-f Y -_ d 1 Town of Barnstable -/ 6 - 1133 oFtrie rpk, *Permit# P� O Expires 6 months from issue date * Regulatory Services Fee 3 s 639; Richard V.Scali,Director Building Division MAY 03 2016 Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 TOWN OF BARNSTABLE www.town.barnstable.ma.us Office: 508-8621-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Properly Address �1 n l� AY h 1 fy)'A ®Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Cof 1 C,G�P_� Contractor's Name-paW Telephone Number — `fd•6 �� Home Improvement Contractor License#(if applicable) Email:3 (:Q_(D()D_ l , C,�� Construction Supervisor's License#(if applicable) OVorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner have Worker's Compensation Insurance Insurance Company Name &(1p Workman's Comp.Policy W077 da�s Copy of Insurance Compliance Certificate must accompany each permit. Permit Reque (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 ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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 Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2PIOIDHR\EXPRESS.doc Revised 040215 The Coninzonwealth of Massachusetts Department of Industrial Accidents Office oflnvestiDations 600 Tf ashington Street Boston, MA 02111 wwiv.mass.gov1dla Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): PII.-/L Address: C® / XfA IAJ S — Ci-s,/State/Zip: LC MA Phone#: Are you a -.employer?Check the appropriate box: Type of project(required): 1. am a employer with/0 i4-17"`t�4. I am a general contractor and I 6 New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.❑ I s These sub-conctors have 8. � Demolition hip and have no employees am a sole proprietor or partner- tra working for me in;any capacity. employees and have workers'comp. Building addition [No workers' comp. insurance comp.insurance. required.] 5" ❑ We are a corporation and its _ 10.❑Electrical repairs or additions 3.El lam a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions right of exemption per MGL myself. [No workers comp. 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and.we have no d —/eoo employees. [No workers' 13.•12-0ther 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. d am an employer that is providinc workers'compensatioiz insurance for znj�employees. Below is the policy and job site information. Insurance Company Name: L-f k1 !/V S c o a - Policy#or Self-ins.Lic.#: W&•6— 3/ —3��6��J2 S_ Expiration Date: f O/l Job Site Address: 8�) ffLIK ')4 1`eve City/State/Zip: (4)1IS �� Attach a copy of the workers' compensation policy declaration page(showing the policy num er 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 certify under the pains and penalties of perjury that the information providedt above is true and correct. 9_� Date: Signatui e — Phone#: �— �f2 L'—�J Official use only. Do not write in this area, to be completed by chy or town officiaL City or Torvn: 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 fr: DATE(MM/DD/YYYY) ✓ acoRo® CERTIFICATE OF LIABILITY INSURANCE 8/11/2015 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 DOWLING & O'NEIL INSURANCE AGENCY INC NAME:CONTACT 973 fYANNOUGH RD PHONE FAX PO BOX 1990 A/C IL Ext: (A/C. AIC No HYANNIS, MA 02601 E-MAIL ADDRESS: INSURERS)AFFORDING COVERAGE NAIC# INSURERA: LM Insurance Corporation 33600 INSURED INSURER B PAUL J CAZEAULT& SONS INC 1031 MAIN ST INSURER c: OSTERVILLE MA 02655 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 25918664 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 ADOLTYPE OF INSURANCE INSD SUER POLICY NUMBER MM DDY/YYYY EFF MM LTR /DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO I CLAIMS-MADE Fl OCCUR PREMISES (E.occTu ence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JET LOC PRODUCTS-COMP/OPAGG $ OTHER: AUTOMOBILE LIABILITY -COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTO S AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY tDAMAGE $ HIRED AUTOS AUTOS Per acc den UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC5-31 S-386670-025 8/10/2015 8/10/2016 �/ STATUTE - ERTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE Y/N N/A E.L.EACH ACCIDENT $ 1000000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1000000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1000000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) I WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION PAUL CAZEAULT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION' DATE THEREOF, NOTICE WILL BE DELIVERED IN 1031 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. OSTERVILLE MA 02655 AUTHORIZED REPRESENTATIVE LM Insurance Corporation JI - ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 25918664 1 1-386670 1 15-16 WC I shankar.gadaleOlibertymutual.com 1 8/11/2015 4:45:09 AM (PDT) I Page 1 of 1 � - --� Office of Consumer Affairs and Business Regulation 10 Park Plaza Suite 5170 Boston, Massachusetts 02116 Hone Improvement Contractor Registration Registration: 103714 Type: Supplement Card Expiration: 719/2016 PALL J. CAZEAULT & SONS, INC:..' .... ... . .. : . RUSSELL CAZEAULT 1031 MAIN ST -- OSTERVILLE, MA 02658 Update Address and return card.Mark reason for change. SCAT 4, 20M-05111 Address Renewal Employment Lost Card C� ��/I!•!.' fOL+YY'!./780%%lG(;CI.F�I(•L�C;(�L;i:JC(.G'�C4LLlJ '`—Office of Consumer Affairs&Business Rc alation >; License or registration valid for individui use only � t` e before the expiration date. If found return to: Ii OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation y Registration;;:;j.03714 Type: 10 Park Plaza-Suite 5170 Supplement Su Expiratibri.:::7%9/20:1fi:;• pp "andBoston,MA 02116 PAUL J.CAZEAULT&'SONS;INCi RUSSELL CAZEAULT..,-..{ 1031 MAIN ST OSTERVILLE,MA 02658 Undersecretary Not valid with nature 4I iUlassaCnusetts -Department-`Ji Public Safety i r :Board of Buiiding Regulations and Standards Construction supw-1-isor a License: CS-108157 = RUSSELL CAZEAULT..,_— 2071 MAIN STREET Brewster Aa 02631 Cnrrm;ss;llner 1 1/2312 0 1 8 I: Property Owner Must Complete & Sign This form 5 If Using a Roofer / Builder. as Owner / Agent of the subject property hereby authorizes Paul J. Cazeault& Sons Roofing Inc. to act on my behalf, in all matters relative to work authorized by this building permit application for: ,J PK Address of Job 3 T 4e. Q -A n �►) Signature of Owner ' Mailing Address of Owner Any)I 9 ii } Telephone# Geli a Date Cl f i 1 a Please return this form to Paul J. Cezeault Roofing along with your signed contract. It is needed for us'to obtain the building permit required by your town to complete your roofing project fax#508-420-4555 office d@cazeault.com