The URL can be used to link to this page

Home My WebLink About0035 PLEASANT PARK AVE 3S ^Pl eQ-s�{ �Q.�,-k I��re... _ SIC, OF T HE Town of Barnstable *Permit# Expires 6 months from issue date * Regulatory Services Fee • M BARNSTABLE, v� Mass.039. Richard V.Scati,Director �0 Building Division ® Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 J�fC a www.town.barnstable.ma.us W� 41N Office: 508-862-4038 sI� ��,[(�� Fax: 508-790-6230 v4pw! - EXPRESS PERMIT APPLICATION - RESIDENTIAL O! a Y zt 441 Not Valid without Red X-Press Imprint Map/parcel Number Property Address ,S- 5 r I NVo '1s,5T F'2,L A-VWLT _ 'Residential Value of Work$ (CmciUO Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address CA 'IM01 Fhmt(!a' na:*4`(DrT_ '^ML)ST7 206 ca 6 Contractor's Name (2>0&UU Qrzc gyp, T()c- Telephone Numbe%" - ' Home Improvement Contractor License#(if applicable) Email:(1!a,h&A)C 10,cicka-1 Construction Supervisor's License#(if applicable) '�j ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 'R I have Worker's Compensation Insurance /1 Insurance Company Name Fum I�US►7rLIE,�t�C-Q cp Workman's Comp.Policy#, Q 114222 ; Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) �Re-side Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note:. Property Owner must sign Property Owner Letter of Permission. A copy of the Ho mprovement Contractors License&Construction Supervisors License is required. SIGNATURE C:\Users\Decollik\AppData\Local\Microsoft\Windows\Tempor Internet Files\Content.Outlook\2PIOI DHR\EXPRESS.doc Revised 040215 ?lee Commonwealth of Massachusetts Depaptnrent of Industrial Accidenis Offace of Investigations ta 600 Washington Street Boston,M4 0-7111 ww w..massgov/dia Workers' Compensation Insurance Affidavit:BuilderslCon etor ctrir s/Plumbers Applicant Information ease Print Legibly D AA&ess: t to 51 2c D, soh—, , St CitylStat&Zip: e# - �$Are you an employer°' the appropriate boss: T of project r 4_ I am a general contractor and I Y3� Pr ] ( e 'ed}= l_�I am a employs with� ❑ 6. ❑New construction employees(full andlor pact-time).* have fired the sub—contractors 1❑ I am a sole proprietor or partner- listed on a attached sheet. `i- ❑Remodeling slip and have no employees 11ese sub-contractm have g. ❑Demolitkm working for me in any capacity_ employ and have workers' 9. ❑Building addition [No workers'comp-insurance comp.ins r 1 required.] 5. ❑ We are a corporation and its. 10_❑Eketrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L Plumbing repairs or additions myself [No workers'comp- right of exemption per MGL 12.❑Roof repairs insurance ]I c- 152, §1(4 and we have no 13% tither S lvt employees-[No t comp"insurance mired] *Any appHcant that checks box#1 also fill out the section below showing their woders=couqwmsatimpoUry information- T Eknneovmm who submit this affidzv t uAk-ating they are dare all waft and their hire outside contractors mm subnut a new affidavit indicating such- kGontractors that check this box must attached am additional sheet shy the of the sub-contr3ctars.and state whether or not those entities have employees_If the have they mast pride thefir wadLere comp.pahcy number_ I am an employer that isprovift workers'com pernsation insurancefor my employees. Below is the potiey and job site information. n Iusuraace Company Name: MPAICWJ�r, 5rZ'L ThE4)rZMre 1p. off` kc) Policy 4 or Self-ins.Lit:.g- 0 14=8G9 Expiration Date:' 1 Job Site Address- P�?.� a V Z C tylStaWZT: 1 Attach a copy of the workers'compensation policy declaration page(showing the policy aum er and won date). Failure to secure coverage as requited ands Section 25A ofMGL to 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 m 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 forded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby can under the and aItias of perr�ruy tb info n pro dec[aboU)'L ` and correct Si tur _ te: Phone#: t7fflciat use onl5p to not write in this area,to be completed by city or tmm officiaL City or Town: PermitUcense b Issuing Authority(circle one): 1.Board of Had& 2.Building Department 3.CityfTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 r r * BARNSfABLE, MA 9cb 639 ,m� Town of Barnstable A FO MA'S Regulatory Services Richard V.Scali,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 I 9,11.1 15. 67,1 l as Owner of the—subject ro er �c` property �' hereby authorize (24?✓J00-v 40-Y" to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) -7 U)X 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\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\2P[O1 DHR\EXPRESS.doc Revised 040215 Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-005157 _ Construction Supervisord7' yt^� t y JIR I ROLAND B CATIGNANI 60 GEMINI DR Jr. p W BARNSTABLE MA102668 ' /n t� -'1 tit t� I SM b' — Expiration: Commissioner 05/23/2018 ' ,.,> "F/�c �cvirrrnaritcecr.�/�a�d��ir�rtc�c%e/lt -Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR ( Registration:< 130110 Type: Expirafion i/Zt2018 [ Private Corporation CON SERV GROUP INC_ � t' ROLAND CATIGNANIY 110 STATE RD SUITE 7yk SAGAMORE BEACH, MA 02562 Undersecretary s 3 V.RTCIFICATE -29-'16 10:39 FROM- 603-641-5062 T-877 P0001/0001 F-399 zar CERTIFICATE OF LIABILITY INSURANCEDATE(MNI/DD/YYYY)7/29/2016 RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 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($), 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 pollcles may require an endorsement A statement on this certificate does not confer rights to the certifleate holder in lieu of such endolsement(s). PRODUCER NAME: Lynn Blanchard, CIC,CISR FIAT/Cross Insurance PHONE (603)669^3210 FAX (603)645-4331 AIC No 1100 Elm Street E-MAIL .lblanchard@croaaagency.com INSURER(S)AFFORDING COVERAGE NAIC A Manchester NH 03101 INSURERANational Fire ins Co of Hartford 20478 INSURED INSURER B ConSery Group, Inc. INSURER C 110 State Road, Suite 7 INSURERD: INSURER 6: Sagamore Beach MA 02562 INSURERF: COVERAGES CERTIFICATE NUMBER:16-17 WC 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 PODGY EfF POLICY EXP Lis TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S DAMAGE TOCIAIMS�IADE �OCCUR PREMISES R S MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L-AGGREGATE•LiMrr-APPLIES•PER. - -GENERAL-ADGREGATE— $ - •• •• POLICY JEC LOC PRODUCTS-COMP/OP AGG S OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLEI S ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per aociCenl) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS pnr $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 4CESS UAB HCLAIMS-MADE AGGREGATE o"E10 RETENTIONS S WORKERS COMPENSATION 6014222e69 X AND EMPLOYERS'LIABILITY Y/N TATi RF ER ANY PROPRIETORIPARTNERIFXECUTIVE NIA A (5a.) DW 6 CT EL FACH ACCIDENT E 500 000 A (Mandatory In NH)EXGLU0Eo7 All officers included 7/1/2016 7/1/2017 E.L.DISEASE-EA EMPLOYEE $ 500,000 If Yr,dwc&e a dar DESCRIPTION OF OPERATIONS bobw E•l-DISWF-POLICY LIMIT $ 500,000 i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addidonid Remw*es Schedule,mny be adaehad if mote space le raqulred) CERTIFICATE HOLDER CANCELLATION (508)790-6230 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable, MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS- Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE M Guarino/,7SC 9)1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD INS025 r.?rttenrl