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HomeMy WebLinkAbout0790 IYANNOUGH ROAD/RTE132 - Unknown vk"®L-)�-N CA, TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma Parcel (O Application #ru r Health Division Date Issuer Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address 7t0 =�(aw��. 4NAr►n�s MN 01ID(ok Village Owner CAM Towv, 'Qko%zA U'L Address Po. 60� 3(O155, CVY4C%1. 1f Telephone (011- (,Klo -32to4 Permit Request t2c+�o�� tires ektsp ,�&k 4364fe ` dower 'Vo S4 rUu AVrQ1 -nk4N kik . Tv%*-% li A� o V' A AeW (eo m. \ TPO rwr, sys�cw. v#•:I;z;..� -1-hc. 19A,;, ta3.d iruUxhioi, �(yk wwl�llt Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay ffi Project Valuation S41.5ob•— Construction Type'CC•coo�. °l'1�5� �. �• :Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. . --i Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) .- - Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kings Highways ❑Yet ❑ No 173 Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other s 01. Basement Finished Area (sq.ft.) Basement Unfinished Area (sgft) Number of Baths: Full: existing new Half: existing new r' 3 \.wf E i9 .y Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing' ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: g Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑f Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name CEO+, 8ru N+- (.A+tA Q.coyZro,� Telephone Number ai8-415.45co Address 114 License # CIS- 0934 b 8� � tt�` Mpt ol$tn Home Improvement Contractor# Email coorex-m- P c mroopina- het- Worker's Compensation # 1N(AyoyNook ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO F�k-6, j%, AM� Owtrk C or�rc. CoMptih;eg SIGNATURE DATE 14-Sgp-lay i t FOR OFFICIAL USE ONLY S F, APPLICATION# DATE ISSUED - MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ` ELECTRICAL: ROUGH FINAL ,. PLUMBING: ROUGH FINAL - GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT AS_SOCIATION.PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 . www mass gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): A & M Roofing ServiCeS Address: 123 Tewksbury St City/State/Zip:Andover/MA/01810 Phone#:978-475-4500 Are you an employer? Check the appropriate box:, Type of project(required): 1. ■❑ I am a employer with 60 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I 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.1 required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 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 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:AIM Mutual Insurance Co Policy#or Self-ins. Lic. #:WC4164369 Expiration Date:05/15/2015 Job Site Address: 1°lV Z`FArlt�ov9t(� Qct. City/State/Zip: 4No,%h;S 1 Mal D1.oly� 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: I-y' _Ul`k 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#: ASMROOF-03 LCARUSO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD)YYYY) 5/13/2014 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(les)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 endorsemen s). CONTACT PRODUCER NAME: Salem Five Insurance Services,LLC HONE :(781)933-3100 FAX No): 781 933.9048 445 Main Street Woburn,MA 01801 ADDRESS: INSURE S AFFORDING COVERAGE NAIC 0 INSURER A:Acadia Insurance Company 31325 INSURED INSURER B:AIM Mutual Insurance Co. 0913 ABM Roofing Services LLC INSURER C:Scottsdale Insurance Company ABM Roofing&Sheet Metal Co Inc INSURER D: 123 Tewksbury St Andover,MA 01810 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 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. ILTR TYPE OF INSURANCE POLICY NUMBER M �pY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTE CLAIMS-MADE [)(]OCCUR CPA0110399-20 05/15/2014 05/15/2015 PREMISES Ea occurrence $ 250,00 X XCU not excluded MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY T jECT LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: AUTOMOBILE LIABILITY Ea OM aaa�eD SINGLE LIMIT $ 1,000,00 A ANY AUTO MAA0110400-20 05115/2014 05/15/2015 BODILY INJURY(Par person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NUT SWNED PROPERTY DAMAGE $ X X Per accident $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,00 A EXCESS LIAR HCLAIMS-MADE CUA0110401-20 05115/2014 05/1512015 AGGREGATE $ 5,000,00 DED I t RETENTION $ WORKERS COMPENSATION X S pRE OETRH AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN LETTER ID-4164369 05115(2014 05/1512015 E.L.EACH ACCIDENT $ 1,000,00 OFFICEWMEMBEREXCLUDED? FN N!A 1,000,00 If y (Mandatory in NH) E.L DISEASE-FA EMPLOY $ DESCRIPTION OF OPFAAdescribe under TIONS below E.L DISEASE-POLICY LIMIT $ 1,000,00 C Umbrella(C) #102572376A 05116/2014 05/1512015 Limit:$5,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be a@ached H more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Mgssachusetts -Department of Public Safety' ',Board.of Building 9 Re ulation.s and Standards Construction Supervisor 'License'.CS-093468 CRAIG D BRECHgo- '��. 79 MEADOW RD BEDFORD NH 03110� Expiration Commissioner 05/15/2015 i P f BARNSTABLE, = i. , MAS& ,.� Town of.Barnstable A�FO.�r p Regulatory Services Richard-V.ScaliDirector Building Division Thomas Perry,CBO. Building Commissioner 200 Main Street, Hyannis,MA 02601 wrvw.town.b ar n s to b l e,to a.u s Office: 508-862-408 Fax: 508-790-6230 Property Owner Must Complete:and.Sign This Section If Using A Builder zI � n� l �;�' ; ,as Owner of t}e.subjeet property l hereby authorize �t',MF: SeN�GC S to act on my behalf, n all lnattets relatideao W6tk,authorized bp't]iis building permit application for: 79�.. =ygnriou�l "Y; M.:A 02ote K" (Address of Job) i signatur Owner. Date GN �D�� zMgRK3 Print_N= f. If :O ` owr' sar' m mete'the Homeowners License Exemption Form on the re'derse`side: QAWPFILESTORMS\bu ldipg permif'fgrm TVR W.doc Revised`061313 f Mass. Corporations, external master page Page 1 of 2 G{ �i =61 R p 19 x � a t Corporations Division - Business Entity Summary ID Number: 001053027 Request certificate l New search Summary for:, CAPE TOWN PLAZA LLC The exact name of the Foreign Limited Liability Company (LLC): CAPE TOWN PLAZA LLC Entity type: Foreign Limited Liability Company (LLC) Identification Number: 001053027 Old ID Number: Date of Registration in Massachusetts: 05-13-2011 Last date certain: Organized under the laws of: State: DE Country: USA on: 10-15-2010 The location of the Principal Office: Address: 1330 BOYLSTON ST., SUITE 212 City or town, State, Zip code, CHESTNUT HILL, MA 02467 USA Country: The location of the Massachusetts office, if any: Address: City or town, State, Zip code, Country: The name and address of the Resident Agent: Name: WS ASSET MANAGEMENT, INC. Address: 33 BOYLSTON STREET SUITE 3000 City or town, State, Zip code, CHESTNUT HILL, MA 02467 USA Country: The name and business address of each Manager: Title Individual name Address MANAGER WS CAPE TOWN LLC 1330 BOYLSTON ST., STE 212 CHESTNUT HILL, MA 02467 USA ` The name and business address of the person(s) authorized to execute, acknowledge, deliver, and record any recordable instrument purporting to affect an interest in real property: 4 http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.... -9/29/2014 Mass. Corporations, external master page Page 2 of 2 Title Individual name Address REAL PROPERTY RICHARD A. MARKS 1330 BOYLSTON ST., SUITE 212 CHESTNUT HILL, MA 02467 USA REAL PROPERTY JEREMY M. SCLAR 1330 BOYLSTON ST., SUITE 212 CHESTNUT HILL, MA 02467 USA REAL PROPERTY THOMAS J. DESIMONE 1330 BOYLSTON ST., SUITE 212 CHESTNUT HILL, MA 02467 USA REAL PROPERTY DEIRDRE A. GEOGHEGAN 1330 BOYLSTON ST., SUITE 212 CHESTNUT HILL, MA 02467 USA r r Confidential r Merger r Consent Data Allowed Manufacturing View filings for this business entity: h :/ ALL FILINGS Annual Report Annual Report - Professional Application For Registration Certificate of Amendment View filings Comments or notes associated with this business entity: FNew search http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.... ' 9/29/2014 � - - -- -- ; - - Tom• - A&M Roofing Services 5eptember 29, 2014 Town of Barnstable Building Department 200 Main Street Hyannis, MA 02601 To Whom This May Concern; Craig D. Brecht is n Vice President at A&M Roofing Services, LLC, If you need any additional information, please contact our office. Sincerely, i John J. Leary Executive Vice Presiders Craig 0. Brecht Vic( Prowdent•Pminer A&M Roofing Services, LLC t 123 TewkAwry Street.Andover,MA 01010 PHONE 970-475-4bOO•FAX 970.475 8778 tMAQ. chrAcht®BRlrvoling-09t 123 Tttivksbwy Street-Andover MA 01610 11,oNc ol1$-475-4500, fAk.976.475-6778 f Mass. Corporations, external master page Page 1 of 2 Corporations Division Business Entity Summary ID Number: 261369450 Request certificate I New search Summary for: A&M ROOFING SERVICES LLC The exact name of the Domestic Limited Liability Company (LLC): A&M ROOFING SERVICES LLC Entity type: Domestic Limited Liability Company (LLC) Identification Number: 261369450 Old ID Number: 000967389 Date of Organization in Massachusetts: 12-27-2007 Last date certain: The location or address where the records are maintained (A PO box is not a valid location or address): Address: 123 TEWKSBURY STREET City or town, State, Zip code, ANDOVER, MA 01810 USA Country: The name and address of the Resident Agent: Name: JAMES A. LOOS Address: 123 TEWKSBURY STREET City or town, State, Zip code, ANDOVER, MA 01810 USA Country: The name and business address of each Manager: Title Individual name Address MANAGER JOHN J. LEARY 123 TEWKSBURY STREET ANDOVER, MA 01810 USA MANAGER JAMES A. LOOS 123 TEWKSBURY STREET ANDOVER, MA 01810 USA MANAGER ALLEN P. MARIN 123 TEWKSBURY STREET ANDOVER, MA 01810 USA MANAGER BARBARA M. MARIN 123 TEWKSBURY STREET ANDOVER, MA 01810 USA MANAGER JAMES W. MURPHY 123 TEWKSBURY STREET ANDOVER, MA 01810 USA http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN... 9/29/2014 Mass. Corporations, external master page Page 2 of 2 In addition to the manager(s), the name and business address of the person(s) authorized to execute documents to be filed with the Corporations Division: Title Individual name Address SOC SIGNATORY JILL E MANN 161 SOUTH MAIN ST MIDDLETON, MA 01949 USA The name and business address of the person(s) authorized to execute, acknowledge, deliver, and record any recordable instrument purporting to affect an interest in real property: Title Individual name Address REAL PROPERTY JAMES A. LOOS 123 TEWKSBURY STREET ANDOVER, MA 01810 USA REAL PROPERTY JOHN J. LEARY 123 TEWKSBURY STREET ANDOVER, MA 01810 USA 0 OConfidential 0Merger El Consent Data Allowed Manufacturing View filings for this business entity: ALL FILINGS Annual Report Annual Report - Professional Articles of Entity Conversion j Certificate of Amendment V View filings Comments or notes associated with this business entity: n - .v New search r http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN...1 9/29/2014 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map- Parcel plication # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board - Historic - OKH _ Preservation/ Hyannis Project Street Address —Jd0 =yahv►a►x�h. Qd. Village Owner Gave. Tow . ?tqa LLC 'I S.Z. Wc;ne� Address 133o tioyl�. S+.. 0_9Y .* 1'4�11 AAA Telephone (6 0) (Ar-3212 024#01 Permit Request 944* mc. aft� cX''bu og ex:sV.!n* roc;: sysAed , down. A* Skro�� Mtn At(*. SWA%1l (1) hCw Oven of Zu ooly i,o Cyun mJv- inS t%41c" clna q new (d m;1 Fvl l 4(II&M E ADM rep F Sy s few Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation "141,9QD. ` Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kings Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wocdP/,oal sto ❑Qes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: 0 existing new.�size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: 2�t ;Z Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ -� m v Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER-OR HOMEOWNER) - _ - Name YRm Se-ry�Le.S Telephone Number (9`18� 415'ys� Address i�3 Tew'fS6s?q License # GS- DRS4 (v k tlndoVer, N1 omo Home Improvement Contractor# ti Email Worker's Compensation # %(_Q(a-10244 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE c3z/� ` FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: < FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH ` FINAL PLUMBING: ROUGH FINAL- , GAS: ROUGH FINAL FINAL BUILDING t DATE CLOSED OUT ASSOCIATION PLAN NO. = The Coinnioiwealth"ofMassaehuset&t.s Y :� d i� F+44 :Yx3i ryre9 } 1 4 DepWbii t of Industrtal,Acc dents �* 1 - 0ffice of Itiivestagahons �` t - .* ' +° 6W0hnonSr k Boston,lilA 02/111 „ram4.n. .;� '� wwwiln�s�gov/�la'�t ;• � �' t? �Y s ' s Workers' Compensation Insurance Affidavit:Bnilders/ContractorsMlectrici<anslPlumtiers{ Aoalieant Iuormation rv:€` ' s ` " `' lh _ ' 'R ' =Please Print Leibly .3.. :`C ,C...n .....:2. ,,� $.,. �� a i� s +•e " P 3 e€. $,�. A&k,y �vFn ai' ,,k Y*�n t � +•etz ,a N 1Ile(Business/Organza ion/Indtvtdual) A&M yRdo - ng�SeryiCes, Address: .=12 3= Tetaksburyx Street,. _< � ; ' � �£.' rf w City/State/Zzp.' Andover;: MAj 01810w, phone;# (4978)475 w. _.y >. . .�,,, Are you an emwploYyer?Check the appropyriate`box �y z T be of ro1ect(required) , !` h � � �T` ]i�+S 'fs.� '3,.' 4°• "`Yy, ..A .} yl' ;v � iV� '\ } - 1 ® I am a employer wrthy 6 0 4 0 I am a general contractor and I �n f s have hued the crib ont actors r{`6 New construction s.xr employees(frill and/or paitftime) 4} t, - x listed ontthe'attachei sheen ' z7Q Remodeling . 2 I am a"sole proprietor or partner ;. d4� g Y r These sub contractors have k ship and have no employees [] -.... ex. •.,...+« >,w;>�w�>n , •+` -$�'�z-•,.� I)e olrt o ,".,..a.. yr h,•., K"-:s. workingforme m;an ca acr $ employees and have<woike'r"s . Y :,p „tY � 9 �Building addition ,"�A coin insurance$ m[No workers comp:insurance p 5 Q We are'a-corporation and its 10 0 Electrical repass of additions .required l .. - t ? 3.( VI arri a homeowner doing all"work officers have exercised their 11 Plurnbur re airs or additions . , F ❑ g p myself [No workers' comp. 4 w,gfrrght ofexemptton pet MG)✓ a r 12:( Roo£repatr8 insurance required.]t Jai c 152, §1(4) and w'e have no J eriiployees .[No w6rkers' � 13 a :comp,insurance requu e'd] *Any applicant that checks box#I mast also fill out.the section:below showing thu.&workers coinliensat►on policy information: k >Nz t Homeowners:who submit this ihdavii iacatiii .t ey are doing all.work and then hire outs'de contractors must sub,�mt a new nffidavtt;axlicating such Contractors that check-this box`must attaehed an additional sheet showing the name of tlie:`sub contractors and state whether or not those'entities have einployees'�Tf the suU=coritrac toes'have employees,they imist'provide�theu workers eomp policy riumbei t' kxF 1 ani,an em"to er that n;. r`ovrdin workers'compensation uisuranee for my employees BeCow rs tree poluy and job site Insurance CompanylVame. Star.. Insurance r Policy#of Self tns'.Lrcr# WC0670244r 'Exprr'atron Date: *5/15/14 Job Site Address ��� aTya► cti, ` 41zd�• City/State/Zipgi ►4 7�--�b2tOo.1 Attach a copy of the workers'conipensahon policy declaration page(showiag too,:poilcy number and eiepiration Failure to secure coverage-as required under Section 25A of MGL c. 152 can.lead io.the imposition of criminal penalties of a:, rise up to$I 500 00 and/or one year imprisonment,as waif as civil penalties.in;the form of.a STOP WORK'QRDER and a fine of up to$250 00 a day against the,violator:;Be advised3hat a copy of this statement may be forwarded to the Office of ' Investigations of the DIA for insurance coverage verification. 1 do hereby certi "ender lire i and penalties of perjury that the information provided above is true and correct. Si store: �� _ Date 3' ( `: Phone#: (978)475-4500 Offlcial use only.'Do not wide in this area,to be completed by city or town.official. City'or Town: Permit/lacense# r Issuing Authority(circle.oue): 1.Board of Health 2.Building Department 3.City/Town.Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i iI*nfOratt� nsr { �� + Y a4 - ; ti„3'-0r-fi F:',„, 7a�^Y,xi� uS„ ^a. J ? • F s,h g Y Y w�� z Nlessachusetts General`Laws chapter,15246quires allwemployers to provide workers'co ensation for their a to ees Pilrsuantto this:statute an em do ee is.defined as ev a•' . p y ery person in the service of another under:any contract ofhire, express or implied;oral or,written G An employer is defined as-an uid�dIial,parmerslup,association,corporat or or other legal entity,or any two-or more of.the foregoing engaged iti a joint enterprise;aril including the legal representatives of a deceased employer,or the receiver or trustee of an fichvidual,part; ership,,assoc ahon or other leg .,erittty;employing employees"`'However theP owner of a dwelling house having not more than three apartments and who resides therein,or the,,occupant dwelling"liouse;of another who employs persons to do maintenance,construction or repair work on such.dwellingihouse or on the grounds or building appurtenant thereto shall not because of such employment be.deemed to-,,be an employer:',';,,; . MGL chapter 152, §25C(6)also states that"every state*oraloeal Ifcensing ag ency�shall withhold the=issuance or, r. i eriewaf of a license or permit to operate`a liasiness'or to construct buildings iri'the co``nmonweafth for any w y Y applicant who.has not produced acceptable evidence of-compliance with.the insurance coverage required Addrti on-ally,MGL chapter`152;§25C(7)states �leitt er the commonwealth not any of its political subriivisions"shall enter into any con,tract for the performance of public work until acceptable evidence of coinpharice with the insurance .: requirements of this cha�.,pter have been presented to the contracting authority." ' Applicants t L , Please fill out the workers'compensation affidavit completely;by cl eckingAe boxes that apply to your situation and,if necessary;supply'sub contractors)narrie(s),addiess(es)and phone number(s)along with their�certificate(s)of insurance. Limited Lability Coirrpairies(LLC'j Lim ted"Ll"A ilityPartneiships(LLP)with no employees other than the members or partners,are not required equired to carry workers'copensation insurance:. If an LLC or LLP`does'have` employees a policy is iequired"';Be advised that this,af idavit may tie submitted to the Department of Industrial Accidents, confumatiun of insurance-coverage ;Also be sure to,sign,and date,the affidavit. .-The-affidavit should , be.returned to the city or town that the application for the pernut or license isrbeuig i equested;not the Department of Industrial Accrderits Sho"uld you have any questions regarding the law or if,you are required to obfarn a woikers'` compensation policy,please call-ahe Departmenat at the number listed'below..Self=insured companies should enter.theu self-insurance icense.number•onthe appropriate line: . . . q�8 Sd id oi, City or Town.Officials - Please be.sure that the affidavit:is complete and printed legibly. The-.Department has provided a space of the bottom of the affidavit for you to`fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to rill Jn the perm t%hcense ni inber which will be used as a reference nuinber In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)'and tinder"Job Site Address"the applicant should rw`rite"all locations`in (city or, town)."A copy of the affidavit.that has�been officially.stamped ormarked lay the city or town may be provided to the applicantas proofthat a valid affidavitis on file-for future permits or licenses: A new affidavit must be filled out each year:'Where a'.11 owner or citizen is obtaining a license or permitnot related to any buMness'br commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete`this affidavit. The Office of Investigations would lrlce'to thank you in advance for your cooperation and should you have any questions; please do not hesitate to give us dc'all. The Department's:address,telephone and fax number:- The Commonwealth of Massachusetts ►epattment of Industnal-Accidents 'Office,of roves,dp Mons 600 Washington Street Boston,MA 02111 Tel. #617-7274900 ext 406 or 1-877-MASSAFE Revised 4-24-07 fax#617-727-7749 wvvw.mass.gov/dia I A&MROOF-03 BSULLIVAN `��orrio� CERTIFICATE OF LIABILITY INSURANCE F DATD/YYYY) 5123/223/2013 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 NAME: Salem Five Insurance Services,LLC PHONE (781)933-3100 5595 FAX (781)933-9048 446 Main Street A/c No Ext: A/C,No Woburn,MA 01801 EMAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC fl INSURERA:Acadia Insurance Company 31325 INSURED INSURER B:Star Insurance Company A&M Roofing Services LLC INSURERC:Scottsdale Insurance Company A&M Roofing&Sheet Metal Cc Inc 123 Tewksbury St INSURER D: Andover,MA 01810 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 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/DD/YYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CPA0110399-19 6/16/2013 6/16/2014 DAMAGE TO RENTED 250,000 PREMISES Ea occurrence $ CLAIMS-MADE �OCCUR MED EXP(Any one person) $ 6,000 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: _ PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY CO Ea accident $MBINEDSINGLE LIMIT 1,000,00 A ANY AUTO MAA0110400-19 6/16/2013 6/16/2014 BODILY INJURY(Per person) $ ALL OWNED 1XX SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOSNON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 6,000,000 A EXCESS LIAB CLAIMS-MADE CUA0110401-19 6/16/2013 6/16/2014 AGGREGATE $ 6,000,000 DED I I RETENTION$ S WORKERS COMPENSATION X I WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC0670244 6/16/2013 6/16/2014 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) - E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under CRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 C Umbrella(C) XLS0088427 6/16/2013 6/16/2014 Excess 6,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,IT more space Is required) - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Proof of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD Massachusetts`-Department of Public Safety Board of Building Regulations and Standards Construction Supen^isor License: CS-093468 CRAIG D BRECII 79 MEADOW RW- � BEDFORD NH 03110" IF Expiration Commissioner 05/15/2015 ® A&M Roofing Services~, April 9, 2014 Town of Barnstable Attn: Building Division 200 Main Street Hyannis,.MA 02601 RE: Building Permit Authorization Please be advised that Craig Brecht is a Vice President of A&M Roofing Services LLC and A&M Roofing&Sheet Metal Company, Inc., its wholly owned predecessor entity. Mr. Brecht is listed as a Director and Vice President of A&M Roofing&Sheet Metal Company, Inc. Despite our inadvertent failure to list it with the Secretary of State, he similarly holds equivalent rank in A&M Roofing Services, LLC. - Mr. Brecht is duly authorized to obtain building permits and make any and all decisions that would compel or legally bind the companies. His signature and representations should be relied upon as being duly authorized on our behalf. If you have any questions, please contact me. Respectively, John J. Leary Executive Vice President 123 Tewksbury Street,Andover,MA 01810 .PHONE:978-475-4500 FAx:978-475-8778 r THE Town of Barnstable Regulatory Services aAxxsrws . ; Miss. $ Richard V.Scali,Interim Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 �Y ProP a Owner Must Complete.and Sign This Section If Using A Builder I, 5121 CkAA D KAXY-S as Owner of the subject property hereby authorize At M T-co;-:tn6 to act on my behalf, in all matters relative to work authorized by this building permit IvaY%n%h6 71.. Vtyo►n►n'�� MIS 02la0t (Address of job) fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. ignature of Owner Signature of Applicant t�� ✓v � Crc�� �ccht Print Name Print Name Town of Barnstable Regulatory Services art Tod Richard V.Scali,Interim Director Building Division snxNs-rascE, # Tom Perry,Building CommissionerMASS, - s s 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6250 HOMEOWNER LICENSE EXEMPTION Please Print DATE:" JOB.LOCATION number street village "HOMEOWNER": name home phone# work phone# CURRENT MAII..ING ADDRESS: cityttown state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Persons)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to tie Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and.other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that,he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Appioval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of-construction Supervisors); provided that if the homeowner engages a persons)for hire to do such work,that such Homeowner shall act as supervisor." ., Many homeowners who use this exemption are unaware that they are assuming the responsibilities"of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness.often results in serious problems,.particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person;as it would witli a licensed Supervisor.-The homeowner acting as Supervisor is ultimately responsible. + To ensure that the homeowner is folly aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form./certification for use in your community. ,