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-- t, � _ .;�Y'ilr.� n:�`rw^� -^"^,w. _, r -t c_ 1 2^. r:.r► _,c. .� r"" �c _ �; ..a. pFTM4E Tpy Tc.;`•wC of Bo rnS*able *Permit# C>)N&V 576r H�P� yp Espires 6 months f ont issue dole Regulatory Services Fee os�. BARNSTABLE. 900 639, � Thomas F.Geiler,Director Building Division 0SS PERMIT Tom Perry,CBO, Building Commissioner 00 200 Main Street,Hyannis,MA 02601 Q C•r 2 www.town.banistable.ma.us _ Office: 508-862-4038 TOWN OF BARN$ 8 b�230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not 11alid without Red X-Press Imprint Map/parcel Number 6o? 6,23 Property Address ( od- i esidential Value of Work ee Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name . , R (�is—�_�> 1;�J't j� Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) 95- /G—) B/Workman's Compensation Insurance Check one: ❑ I am a sole proprietor b am the Homeowner I have Worker's,Compensation Insurance Insurance Company Name a-f ff)C/f FG,_j L Workman's Comp. Policy# j ( ��8,0/ 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 ��\� ci,'a ��- 1 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) h bdC W r11 ❑ Re-side � 1 #of doors VJinciuw /slides. U Valt;e \ (maximum .35)#of windows 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. i ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors,License is SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AA7_\EXPRESS.doc Revised 072110 Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: .�' Registration'Q9601 Office of Consumer Affairs and Business Regulation Expi _ l ;12 10 Park Plaza-Suite 5170 Boston'MA 02116 -- nt Card RENEWAL BY BRIAN DENNIS'- 104 OTIS STREE c < NORTHBOROUGH O'952 Undersecretary N ali ithout signature i i . i I I 1 • 1 a ' .V ssachusetts - Department of Public Safety Board of BuMin- Replations and Staxidards 'Construction Supervisor License License: CS 95707 BRIAN DENNISON . 86 CREST 6IRCLE - F WORCESTER, MA.d1603. - Expiration: SWO12 Commissioner Tr#: 2622 020 Office of Consumer Affairs&Business Begutzfion um OME IMPRO ENT CONTRACTOR Registmaodub 01 Expi 12 e t Card RENEWAL SY BRIAN DENNIS- 104 OTIS SIRE NORTHBOROUGH, ' undersecretary ACORD,, CERTIFICATE OF LIABILITY INSURANCE °"�`M"'°°"YYY' 02/10/2010 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Joseph McKeone ONLY AND CONFERS NO RIGHT'S UPON THE CERTIFICATE JP McKeone Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 333 Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAIC# INSURED Renewal by Andersen INSURER a Hartford Insurance Company ' J and L Windows,Inc. INSURER B: Nautilus 1 O4 OtIS St INSURER C: Northborough, MA. 01532 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION POLICY NUMBER DATE fMMIDDrM LIMITS B GENERAL LIABILITY N C958461 10/01/2010 10/01/2011 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RERTE15-- PREMISES fEa omurence S 100,000 CLAIMS MADE 7OCCUR MED EXP(Any one person) S 5,000. i PERSONAL 6 ADV INJURY $ 1 000,000 ! GENERAL AGGREGATE $ Z 000 000 GEN L AGGREGATE LIMB APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000.0000 POLICY PRO LAC q AUTOMOBILE LIABILITY 35MCC XD 6390 10/01/2010 10/01/2011 COMBINED SINGLEUMIT ANY AUTO (EaaccidenQ $ 1,000,000 X!ALL OWNED AUTOS - s,. SCHEDULED AUTOS BODILY INJURY(Per person) HIRED AUTOS BODILY INJURY. $ NON-0W NED AUTOS (Per accident) PROPERTY DAMAGE s (Per accident) GARAGE.UABILITY _ AUTO ONLY-EA ACCIDENT S ANY AUTO. r OTHER THAN EA ACC 4 i AUTO ONLY: AGG S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F1-CLAIMS MADE AGGREGATE S • S DEDUCTIBLE s i RETENTION $ s q WORKERS COMPENSATION AND 35 WECPP 1444 02/17/2010 02/17/201.1 TO WCRY STAT LIMITS I I DTI+ EMPLOYERS'LIABILITY , ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500.000 It yes,describe under 500 OOO SPECIAL PROVISIONS below - E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION INSURED COPY DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE-CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. • AUiHDRQEED REPRESENTATIVE ACORD 25(2001/08) I @ ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Mglungton Street Boston,MA 02111 "".mas&gov/dia Workers Compensation Insurance Affidavit:Builders/Contractors/ElectriciazLs/Plumbers Applicant Information' Please.Print Lembly Name(Business/orgmindon4ndividud): l 1 Cnp-IJ&I 291,r�erS P YI Address: I D Ni` S - City/Sfate/Zip A O t be�a_ J yJaL_ Phone#: Are you an employer?Check the appropriate box: Type of project (required): 1.E�I am a employer with U7 0 4. []'1 atn a general contractor and I 6, ❑New construction e to ees full'and/or art=time .* haw hired ihe sub-contractors mP y ( P ) 7: deIing 2.❑ I am a sole proprietor or partner- listed on the attached sheet 2 •ship and have no employees .These.sul-contractors have 8. Demolition working for me in any capacity. WW-=' camp.insurancr. 9, ❑Building addition [No workers'comp.insnrarice 5. ❑ We are a corporation and its •10.[]Electrical repairs or additions• required.]. officers have exercised their. 3r❑I am a homeowner doing all work right of eaeniption per MGL 11.❑Plumbing repairs or additions myself[No-workers'camp: c.152,j1(4),and we have nti 12.❑Roof repairs insura=e required.]t employees.•[No workers' ME]Other . comp.insurance required.] `Any applicant that chac m boi 91 must also f m olt the seetioa bdox showingffieir wows'compmsafion policy iaformetioa. t lfomeownen who submit this affidavit indicating flay are doing all wort and thm hire outside contactoa must submit anew affidavit indicating such. . Irontractora thaf cbrlJc this box must attached an additional shed shrug the nmme of the sub-contrnetms and their worlets'camp policy infom�atioa I am an employer that is providing workers'compensation insurance for my employees -Below.1s the po&7 and job site information. nn Insurance Company Name: Policy#or Self-ins:Lie.#: �� ���� l�`>;/ nation Date . Job Site Address: d City/Statamp: CT Ui Attach a copy of the worker 'es ompensation policy declaration page(showing the policy number and ea:piration date). FarIuure 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 civrl penalties in the firm-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 c u er the pains and pencltieap, erjury that the information provided above is and correct 6 F_ Sienahrre: Data. Phone#- Official use only. Do not write in this area,to be completed by city or town q�tcial City or Town: PermitUemse# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3,City/Town Clerk 4.Electrical Jnspector 5.Plumbing Inspector 6,Other Contact Person: Phone M. X Otis St.,Northborough,MA 01532 J&'WINDOWS,INC.,D/B/A MA Home Improvement Contractor '508)919-0900•Fax:(774)987-3013 Renewal License#149601 (Expires 1/24/2012) Andersen. '�'�I Federal Tax ID#83-0404201 WINDOW REPLACEMENT .n MdcmrCompny CUSTOM WINDOW AND DOOR REMODELING AGREEMENT ryerlsl Name Date of Agreement ` MC." 11Q� l a ryerlsl Street Address,City, ,and Zip Code Mail Address Home Tele hone Number Work Telephone Number uyer(s)hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.d/b/a Renewal by Andersen `Contractor"),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached pecification sheet(s) (collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed 11 work under this Agreement. Total Job Amount: Esti cited Starting Date: Method of Pymnt:❑Cash >�Check ❑Mastercard ❑VISA —" tl- O Discover ❑Financed,App#: Deposit Received(33%): P Name on Credit Card: Balance at Start of Job(33%): Estimated Com I tion Date: Credit Card#: Balance on Substantial Completion of Job(33%): rCC Exp.Date: CC Security Code: By initialing here,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion Buyer Initials .;FN of Job cannot be made by credit card and must be made by personal check,bank check,or cash. tuyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties,and that here are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation i-om this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor. Buyer(s) hereby Lcknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a :ompleted,si ed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first vritten above d 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF i SPACES. I&L Win Inc.d/b Renewal by Andersen Buyers Buyer(s) ly: OaMf��. I a4,�� roduct Manager Signature Signature XAHcS F HACUI P£ Print Name of Product Manager Print Name Print Name (OU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD 3USINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS OR AN EXPLANATION OF THIS RIGHT. <- - - - - - - - - - - - - - -:,<- - - - - - - - - - - - - - - -�<- - - - - - - - - - - - - - -K NOTICE OF CANCELLATION X NOTICE OF CANCELLATION )Iate of Transaction . You may cancel Date of Transaction . You may cancel -his transaction,without any penalty or obligation,within I this transaction,without any penalty or obligation,within Three business days from the above date.If you cancel,any I three business days from the above date.If you cancel,any aroperty traded in,any payments made by you under the I property traded in,any payments made by you under the :ontroct of Sale,and any negotiable instrument executed I Contract of Sale,and any negotiable instrvment executed by you will be returned within 10 days following receipt I by you will be retumed within 10 days following receipt by the Contractor ("Seller") of your cancellation notice, I by the Contractor ("Seller") of your cancellation notice, and any security interest arising out of the transaction will I and any security interest arising out of the transaction will be canceled.If you cancel,you must make available to the be canceled.If you cancel,you must make available to the Seller at your residence,in substantially as good condition I Seller at your residence,in substantially as good condition cis when received, any goods delivered to you under I as when received,any goods delivered to you under this this Contract or Sale; or you may, if you wish, comply I Contract or Sale;or you may,if You wish,comply with the with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.If you do make If you do make the goods available to the Seller and the I the goods available to the Seller and the Seller does not Seller does not pick them up within 20 days of the date I pick them up within 20 days of the date of Your Notice of your Notice of Cancellation,you may retain or dispose I of Cancellation,you may retain or dispose of the goods of the goods without any further obligation.If you fail to without any further obligation. If you fad to make the make the goods available to the Seller,or if ou agree I goods available to the Seller,or if you agree to return the to return the goods to the Seller and fail to d o so, then I oods to the Seller and fail to do so,then you remain liable you remain liable for performance of all obligations under I for performance of all obligations under the Contract. the Contract.To cancel this transaction,mail or deliver a I To cancel this transaction, mad or deliver a signed and signed and dated copy of this cancellation notice or any I dated copy of this cancellation notice or any other written other written notice, or send a telegram to Contractor.J I notice,or send a telegram to Contractor.J&L Windows, &L Windows,Inc.d/b/a Renewal by Andersen, 104 Otis I Inc. d/b/a Renewal by Andersen, 104 Otis Street, Street, Northborough, MA 01532, BY NOT LATER THAN Northborough,MA 01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT OF .(Date) OF .(Date) I HEREBY CANCEL THIS TRANSACTION. i I HEREBY CANCEL THIS TRANSACTION. Buyer's Signature Date I Buyer's Signature Date RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink renewal ' • RENEWAL BY ANDERSEN ,ruc License#)4960) p� (expires 1/24/12) Andersen. ut'GREATER AWsACHUsEITS AND NEW HAMPSHIRE Federal Tax ID# 83-0404201 inoow pEitnCEMENT 104 Otis Street•Northborough,Massachusetts 01532 Phone 508.919.0900•Fax 508.919.0903 SPECIFICATION SHEET uye Name Date of Agreemerf i Buyers listed ab ereby jointly and severally agree to purchase the goods and/or services listed below,4 a rdance with the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,of which this Specification Sheet is a part. PATIO DOOR DETAILS 1. Install total of: Permashield Glidirm Patio Doors ❑ 5'10"x 6'8" ❑ Other(not avail9ble in 8068) Op.panel is left M right(as viewed from exterior) Interior and Exterior Color to be: V White ❑ Canvas ❑ dstone ❑Terratone for spe inside and t on PS) Hardware: ❑ White ❑ Stone ❑ Bright Brass [Other—Specify J�' nl� N Vas ❑ Yes Gliding Patio Door to have sidelight? Size: ❑ Yes [g No Grilles? If yes: GBG ❑ INTW ❑ FDL(Pattern is standard as viewed in book for all doors) 2. Install total of: Narrowline Gliding Patio Door(s) ❑ 67 x 6'8" ❑ Other: Op.panel is❑ left ❑ right(as viewed from exterior) Exterior Color: ❑ White ❑ Canvas ❑ Sandtone ❑Terratone (Interior is WOOD and customer must paint or stain) Hardware: Metro: ❑ White ❑ Canvas ❑ stone ❑ Bright Brass ❑ Other—Specify ❑ Yes ❑ No Gliding Patio door to have sidelight? Size: ❑ Yes ❑ No Grilles? If yes: GBG ❑ D47 W ❑ FDL (Full Divided Light) 3. Install total of: Frenchwood Gliding Patio Door(s) ❑ 6'0"x 6'8" ❑ Other: Op.panel is❑ left ❑ right(as viewed from exterior) Exterior Color: ❑ White ❑ Canvas ❑ Sandtone ❑Terratone Interior Wood ❑ Pine ❑ Oak❑ Maple Interior Finish: ❑ Prefinished White(Available only with white exterior) ❑ Unfmished'(Paint/stain done by customer) Hardware: Metro: ❑ White ❑ Stone ❑ Bright Brass ❑ Satin Nickel ❑ Yes ❑ No Gliding Patio door to have sidelight? Size: ❑ Yes ❑ No Grilles? If yes: GBG ❑ INTW ❑ FDL (Full Divided Light) 4. Install total of: Frenchwood Hinsted Patio Door(s) ❑ 6'0"x 6'8" ❑ Other: ❑ Yes ❑ No Active/Passive Panel?: ❑ Left ❑ Right(viewed from ext.which is active) OR ❑ Yes ❑ No Active/Stationary Panel?: ❑ Left ❑ Right Door Swirw. ❑ Inswing ❑ Outswmg .Exterior Color. ❑ White ❑ Canvas ❑ Sandtone ❑ Terratone Interior Wood ❑ Pine ❑ Oak ❑Maple Interior Finish: ❑ Prefinished White ❑ Unfinished(Paint/stain done by customer) Hardware: Metro: ❑ White ❑ Stone ❑ Bright Brass ❑ Satin Nickel 'NOTE: Canvas hinged screen frame N/A—must choose white or stone if exterior is canvas' ❑ Yes ❑ No Hinged Patio door to have sidelight? Size: ❑ Yes ❑ No Grilles? If yes: GBG ❑ INTW ❑ FDL (Full Divided Light) STORM DOOR DETAILS 5. Install total of: Storm Door(s) G. ❑ Full View❑ Mid View 7. Color to be: ❑ White ❑ Canvas ❑ Sandtone ❑ Bronze ❑ Forest Green 8. Size to be. ❑ 32" ❑ 34"(White only) ❑ 36" ❑ Custom(10 week lead time) Size: 9. Hardware to be: ❑ Bright Brass ❑ Nickel 10. Additional job details: 11.V6es ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. No final payment shell be demanded until the contract is completed to the satisfaction cf all parties. It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the entire understanding between the parties,and there are no verbal understartdilags changing or modifying any of the terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both the Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet. Renewal by rea MA and NH Buyer(s) Buyer(s) By: S' Signature Signature -��r.�� � YIP,G✓/,er; Print Name of Product Manager Print Name Print Name Renewal - . byAndersen® �- WINDOW REPLACEMENT an Andersen Company PROPERTY OWNER MUST COMPLETE &SIGN THIS SECTION IF USING A BUILDER J1- G L� J , as Owner of the subject property hereby authorize Renewal by Andersen (d b.a. -J & L Windows) to act on my behalf, in all matters relative to work authorized by this building permit application for- 9 A Y D G o-70 7- odb3s Address of Job Homeowner Si e Date OWNER OR BUILDER(AS AGENT OF OWNER) MUST COMPLETE Est SIGN THIS SECTION I, E l R-t-J � �as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application fo--t C� A-0A--Is Address of Job Signed under the pains and penalties of perjury. Print Name ignature of Owner/Agent Date 104 Otis Street Northborough,MA 01532 Phone (508)919-0900 Fax (508)919-0903 www.renewalbyanclersen.com TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION y � Map 007 Parcel C2 Application # QQ It 6 10y b Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee S 3 •- Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address Village Owners —,UQf z- Address Telephone SO8 `fg $cf Permit Request Z_gn�45�Z �o2N�r�Z ,d-5 VF&Zv v l3 �c Square feet: 1 st floor: existing o2 proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation?,�D.�OO Construction Type V��fi2 Lot Size �,�l Grandfathered: ❑Yes ❑ No If_yes, attach supporting documentation. Dwelling Type: Single Family Fa Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes Cad-No On Old King's Highway: ❑Yes 9-No Basement Type: Wfull ❑ 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: 3 existing —new ID , -a --I Total Room Count (not including baths): existing new First Floor,Room Count ,, Heat Type and Fuel: &,Gas ❑ Oil ❑ Electric ❑ Other =; j _ `1 Central Air: ❑Yes 8,No Fireplaces: Existing New Existing woo /coal st.oye: O�Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing_,,❑ neuv" size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: ; Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) ` Name j� Telephone Number LQF,_J&Z• ;LL21� Address e 7 License # 6 TZe 3 S ©-ro tT- Home Improvement Contractor# Worker's Compensation # 4.4 704:5 28 DI.-In(o ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE Ia FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED p MAP/PARCEL NO. ADDRESS VILLAGE OWNER: DATE OF INSPECTION: r FOUNDATION FRAMEZX INSULATION na, cf �cs,r✓z. FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL .f FINAL BUILDING r DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth ofMassachuse&s DeParbnent of fndusftal Accidents Office of Investkadons 600 Washington Street Boston, MA 62111 Workers) Com ensafion wwfv mars gov1dia P Insurance Affidavit;Builders/Contractors/ A ficant Information IIectricians/PIrmbers Please Print Legibly Name (Bess/OrganizatimVbdividaEq): �c( Address: 5 7- —— Crty/State/zip: G oTc,T hone #: gyp$•j�r7 Q L youn employer? Check the appropriate box: o a emP1oY�whh 4• ❑ I mm a gentxaicontractorandIType of project(required): loyees(mE and/or part-time).* have hired the sub-contractors 6, New construction a sole proprietor or partner- listed on the attached sheet and have no employees These sub-c 7• ❑Remodeling ontractors have g, [�Demolition ing for me in any capacity, employees and have workers'orkers'coin. insurance comp,insurance$ 9. ❑Building addition homeowner doing aIl work 5 we are a coipoi8tion and its 10.[]Electrical repairs or additions officers have exercised their f [No workers' comp• right of exemption per MGL 11.❑Pltmmbing repairs or additions nce required.] t c. 152, §1(4), and we have no 12 0 Roof repairs employees. [No workers' 13.❑ Other � comp,insurance required.]*Amy applicant that checks box#I must also fin out the section below sbowing their workers compensation policy information t Homeowners who submit this affidavit mdicating they are doing an work and thcM h=#Contractors that check this box must atracbed an additional sheet showing the name ouLeide contr'actars must submit a new affidavit indicating such. emPloY= If the sub-contracho s),,,employees,they most proyulz dmir wmk=,a �on�tnrs and state whether or not those entities have °op•Policy number, I am an emrployer that rs prov&=g workers'compensation insurance or injvrmaziort f my employees. Below is the policy and job site Insurance Company Name: 6,� Policy#or Self-ins.Lic.p- Yo[an /Q Expiration Date: Job Site Address: TV Attach a copy of the Workers' compensation Policy City/State/Zip: Failure to secure co re P cp declaration page(shouting the policy number and expiration date}. verage required under Section 25A ofMGL C. 152 can lead to the fine up to$1;.500.00 and/or one-year imprisonment, as well as civil of a S''ion of criminal penalties of a Of uP to $250.00 a day against the violator. Be Penalties in the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance cove advised a copy of this statement may be forwarded to the Office of rage verification• I do hereby e Pan Pe7wy that the lnformtafion Provided ovided ab Si ove is true and correct Date: Phone#: �O$• • �[g�( • Dffzcial use an1y. Do not write in this area to be completed by city or town 0 City or Town: Issuing Authority(circle one): PermitlLicense# 1.Board of Health 2.Building Departmeut lu 3. Chy/Town Clerk 4.Electrical Inspector 5.Pmb' 6. Other mg Inspector Contact Person: Phone#: =; Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 120362 Type: DBA Expiration: 11/30/2013 Tr# 217622 PETER FIELD BUILDING & RESTORATION :. PETER FIELD , P. O. BOX 16 COTUIT, MA 02635 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card DYS-CA1 w 50,%4-04/04-G101216 ✓!�Consumer & a� Regulation License or registration valid for individul use only Office of Consumer Affairs&Business Regulation $ y - ::a HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: f ' Registration: 120362 Type: Office of Consumer Affairs and Business Regulation Expiration: J 30/2013 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 PETER FIELD BUILDING 8 RESTORATION L. PETER FIELD = ! 857 MAIN ST. COTUIT,MA 02635 Undersecretary Not valid with t signatu Nlassachu.wtts- Dcpartmcnt of Puhlic Sa1'ctN Board of Bttildin- Re-_,uLttintts and StandarJs - Construction Supervisor License One-and Two-Family Dwellings License: CS 65638 PETER D FIELD PO BOX 16 COTUIT, MA 02635 .L } Expiration: 7/15/2013 ( uecni.�iuncr Tr=: 1300 � i A A ROC o® CERTIFICATE OF LIABILITY INSURANCE DATE 9`� 011YY' 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 endorsements. PRODUCER CONTACT NAME: G can an ihsumnce Agency PHONE FAX 908 M an S bRetE-MAILc o •(508)428-9194 ac No):(508)428 3068 ADDRESS: O stewalb,M A 02655 PRODUCER CUS D INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: SAFETY INS CO PeterD FE1:1 INSURER B Po Box 16 C Otlti,M A 02635 INSURER C: INSURER D: AM Mutuallls.Co.. 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 TYPE OF INSURANCE DL SUBR POLICY NUMBER MOLICY EFF IPOOLIICDY EXP LIMITS LTRmom A GENERAL LIABILITY :P00001803 9212010 9212012 EACH OCCURRENCE $ 1,000,000 D GE To x NTED COMMERCIAL GENERAL LIABILITY PREM IS EaEoccurrence $ CLAIMS-MADE OCCUR MED EXP Any one person $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO El LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ D WORKERS COMPENSATION AW C 7023784012010 5/162011 5A6/2012 WCSLIMIT o R AND EMPLOYERS'LIABILI Y Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory In NH) E.L DISEASE-EA EMPLOYE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000 _T 'I i - I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION PETER D.FELD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD I S ;dTME, ,, Town of Barnstable Re • gulatory Services � s KARL 639. Thomas F. Geiler,Director ►, • Building Division Tom Perry,Balding Commissioner. 200 Main Street Hyannis,MA 02601 www.town.barnstable.ma.as Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This-Section If US U - A Builder )SAG U/,2/" , as Owner of the subject ro . 1 P Pay hereby authorize to act on my behalf; in all Jnatters relative to work authorized bythis building permit /D A Y ?DASD (Address of Job) * Poo1 fences and alarms are the responsibility of the a li are not to be filled before fence is installed and pools are not to t Pools be utilized until all final inspections are performed and accepted, S' ture of Owner Signature of A he t PP f2t'� F--------------- � — Print Name qp —ltxame Date UOR MOWNERPERMISSIONP00LS L -- s �'IKE Town of Barnstable N Regulatory Services 4 + MASS riwxrterw. Thomas F.Geiler,Director &6 39. �� Building.Division Toni Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-40 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAMJNG ADDRESS: city/town affite p.code The current exemption for"homeowners"was extended to include owner-occl ied-dwellings linos_ `ofiic,suanits or less and . to allow homeowners to engage an individual for hire who does not posse' �ssiailicense;provi ed:that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)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 the Building Officigl om'ra form acceptable E the'Building Official,that he/she shall be res onsible for all such work performed under the buil e=t. (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 Approval of Building Official rIle 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 EXEIGIPIION I,' The Code states that "Any homeowner performing.lw-Wk:forwhi.hl bdhdmg 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 person(s)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,par ticularlye when the homeowner hires unlicensed persons. in this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully 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. Q:fornis:homeexempt I r oho 160il �S Town of Barnstable *Permit# ti Expires 6 months from 'csue da p�AR P'FRAWgulatory Services Fee EBMJW xAst v� 1"3 ��+ �F Z Thomas F.Geiler,Director AR 'VSNat Building Division Tomterry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.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 Property Address J� ��`J l rti"TU IT i wl 10 co [Residential Value of Work r Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address z ►©a ��u _ .L,-ram; T . �, o�s� a Contractor's Name— r� elephone Number 9 1 9- o ( //) Home Improvement Contractor License#(if applicable) 4 �� Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner �I have Worker's Compensation I�nr�surlannce Insurance Company Name 5:Ff Workman's Comp.Policy# S F_ Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders.U-Valu"e u ) v maximum.44)#of windows *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 /es\Content.Outlook\4STGU5QO\EXPRESS.doc Revised 090809 t MA HIC License#149601(expires 1/24/10) Renew �al F�,NEWAL BY ANDERSE. Federal Tax ID#83�0404201 byAndersen. WINDOW REPLACEMENT NAnd.C OF GREATER MASSACHUSETTS AND NEw HAMPSHIRE 104 Otis Street•Northborough,NIA 01532 Phone 508.919.0900•Fax 508.919.0903 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)/Name Data of Agreement CJ I F r' ML- Buyer(s)Sheet ddress,City,54 t,and Zip Code E-Moil Address Home Telephone Number Work Telephone Number Lja Q-'e- SD - -4f? _ff Ad I • q Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.dba Renewal by Andersen of Greater Massachusetts and New Hampshire("Contractor"),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheets)(collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. tL Method of Pymnt:O Cash 4-deck ❑Mastercard ❑VISA Total Job Amount: d Estimat d Starting Date: p Discover O Financed,?pp#: Deposit Received(33%):� Name on Credit Cord: Balance at Start of Job(33%): Estimated-Completion Date: Credit Card#: Balance on Substantial l F'j Completion of Job(33%): In I�O� rCC Exp.Date: CC Security Code: By initialing here,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion Buyer Initials Job cannot be made by credit card and must be made by personal check,bank check,or cash. Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation from this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor.Buyer(s) hereby acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a completed,si ed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written abov and 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE BLANK SPACES. Renewal 1i ders n of Greater MA and NH Buyer Buyer(s) 7 By: i/ r of roduct Manager Sig. Signature P' t N e of Product Manager Print Name Print Name YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. — — — — — — — — — — — — — — —�<- — — — — — — — — — — — — — -1K— — — — — — — — — — — — — — — NOTICE OF CANCELLATION I NOTICE OF CANCELLATION Date of Transaction 'S• (D .You may cancel I Date of Transaction .You may cancel this transaction,without any penal ty or obligation,within I this transaction without any pena ty or obligation,within three business days from the above date.If you cancel,any three business gays from the above date.If you cancel,any property traded in,any payments made by you under the I roperty traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed 1 Contract of Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt I by you will be returned within 10 days following receipt by the Seller of your cancellation notice,and any security I by the Seller of your cancellation notice,and any security interest arising out of the transaction will be canceled. I interest arising out of the transaction will be canceled. If you cancel, you must make available to the Seller at If you cancel, you must make available to the Seller at your residence, in substantially as good condition as I your residence, in substantially as good condition as when received, any goods delivered to you under this I when received, any goods delivered to you under this Contract or Sale;or you may,if you wish,comply with the I Contract or Sale;or you may,if you wish,comply with the instructions of the Seller regarding the return shipment of X instructions of the Seller regarding the return shipment of the goods at the Sellers expense and risk.If you do make I the goods at the Sellers expense and risk.If You do make the goods available to the Seller and the Seller does not the goods available to the Seller and the Seller does not pick-them up within 20 days of the date of your Notice I pick them up within 20 days of the date of your Notice of Cancellation,you may retain or dispose of the goods I of Cancellation,you may retain or dispose of the goods without any, further obligation. If you fail to make the 1 without any further obligation. If you fail to make the goods available to the Seller,or if you agree to return the I goods available to the Seller,or if you agree to return the goods to the Seller and fail to do so,then you remain liable I goods to the Seller and fail to do so,then You remain liable for performance of all obligations under the Contract. for performance of all obligations under the Contract. To cancel this transaction, mail or deliver a signed and 1 To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written 1 dated copy of this cancellation notice or any other written notice, or send a telegram to Renewal by Andersen 1 notice, or send a telegram to Renewal by Andersen of Greater Massachusetts and New Hampshire, 104 1 of Greater Massachusetts and New Hampshire, Hy Otis Street, North o ugh,MA 01532, NOT LATER THAN I Otis Street,Northborough,MA 01532, NOT LATER THA' MIDNIGHT OF 10 .(Date) MIDNIGHT OF, .(Date) I HEREBY CANCEL THIS TRANSACTION. X I HEREBY CANCEL THIS TRANSACTION. I Consumer's Signature Date I Consumer's Signature Date RbA Copy- White Customer Copy-Yellow Customer Covv-Pink res 124/10) newal RENEWAL BY ANDEMEN - "'^Hle Lt enseFedera Tax ID#t 83'0404201 �Rndersen. OF.,,BEATER MASSACHUSL17S AND NEW HAMPSh.BE .o_ ...I....... .. ��M 104 Otis Street•Northborough,Massachusetts 01532 Phone 508.919.0900•Fax 508.919.0903 SPECIFICATION SHEET Bit er(s)Name Date of Agreement KG u The Buyer(s)listed Ake hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance Mth the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT of which this Specification Sheet is a part. WINDOW DETAILS 1. Contractor will Install a total of windows in Owner's home,using the following individual quantities: 10,Double Hung(DB) [ Equal sash ❑ Cottage sash 0/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom) Casement(CW) ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle Double Casement(CDW) ❑ Standard handle ❑ Metro handle Casement/Picture/Casement(CPW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle 2 Lite Gliding Window(GW) Glider/Picture/Glider(GPW) ❑ 1:1:1 or ❑ 1:2:1 Awning Window LAW) Picture Window(PW) Bay or Bow Window Patio Doors(see separate Door Specification Sheet) 2. 1'es ❑ No Qty of Windows to be Custom Fit Replacement: 3. ❑ Yes ❑ No Qty of Sills to be replaced by Contractor: 4. ❑ Yes ❑ No Qty of Windows to be New Construction Full frame(includes new interior&exterior casings) Exterior casings: ❑ Pine ❑ Maintenance-free material ❑ Factory applied 908 Fibrex brickmold 5. Glazing to be: ❑ HP Low-E®SmartSunTMt (Tar 4ed/tLZ{gible) ❑ Other If other,please specify: 6. Exterior color to be:MvIt ite ❑ Sand ❑ Canvas ❑Terratone ❑ Cocoa Bean 7. hnterior color to be: hite ❑ Sand ❑ Canvas ❑ Terratone ❑ Pine ❑ Maple ❑ Oak Note: IV or color can only be white,wood or same color as exterior. Wood interiors need to finished by Owner. 8. Hardware: White ❑ Stone ❑ Canvas ❑ Brass Double Hung: 9. ❑ Yes No Install Lifts with Double Hung mdows 10. Screens: windows to have: ❑ Half or Full screens Screens to be: Vberglass ❑ Aluminum ❑TruScene GRII.LE DETAIIS 11.Windows have grilles: ❑ Yes YNO If yes:❑ Grille Between Glass(GRG)❑ Removable interior Wood omw)❑ Full Divided Light(Frw Qty: Qty: Qty Qty Qty Qty Qty: DH DH DH DH CW/Picture Glider CPWo,GPA Draw grille patterns above 'Use additional sheet if needed Owner approved(initials):( FM ) ADDITIONAL WORK DETAILS 12.❑ Yes Cyl/o Contractor will remove metal frames of windows. Qty of Units: 13.❑ Yes EyNo Contractor will install new paint-ready or stain-ready casings. Inteno casing qty of openings: Exterior casings qty of openings: ❑ Pine ❑ Maintenance-free material 14.❑ Yes [> No Contractor will install new paint-ready or stain-ready inside or outside stops qty of openings: Interior stops qty of openings: Exterior stops qty of openings: ❑ Pine ❑ Maintenance-free material 15. Owner rs a that Contractor does not do any painting. ( .T rK )Owner Initials 16.El No Contractor will wrap exterior casings with aluminum coil stock of color. Note: Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing. 17.K'es ❑ No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. 18.[� ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full. 19. Yes ❑ No Building Permit—Contractor will secure an and all.necessary permits. The fee for the perni t(s)is n included in the Con ct a and se state check is uired at a sale for fee. 20. Additionaljobdetails: � 1 L 21. ❑ Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment. Alo final payment shell Ue demanded until the contract is completed to the satisfaction of all parties. It is an understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELIN ,constitutes the entire understanding between the parties,and there are no verbal understandings changing or modifying any f the t . This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing d signed by the uyer(s)and Contractor Buyers)here knowledge that Buyer(s)has read this Specification Sheet. Renewal by detsen of G r MA and NH Buyer( " Buyer(s) By: tGf/ce� not Manager Signature Signature L*�_ Print Name.of Product Manager Print Name Print Name RbA Copy- White Customer Copy-Yellow �Op1ME Tp� BARN3TABLE, MASS. Town of Barnstable s63y. �0� �AjBC MA't A 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 I, V A nn fJ O t r e , as Owner of the subject property hereby authorizes Iku exC C 0�T to act on my behalf, in all matters relative to work authorized by this building permit application for: t 0<.�6a ()Lddress of Job) Signat&4 of Owr4 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 Intemet Files\Content.Outlook\4STGUSQO\EXPPESS.doc Revised 090809 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ..UT www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizadon/Individual): Ren C i.J a I /V �f1de rs e n Address: /0,Y 0/ S & rem /V ��;r D J.S.3� L�b�� /��l City/State/Zip: Or���, bo>''0 Phone#: O f 6U1 Are you an employer?Check the appropriate box: Type of project(required): L&I am a employer with 00 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t modeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.El am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below.is the policy and job site information. ^^nn Insurance Company Name: �,' � /I/r Ken,n 2 In CIS✓d nC e' Policy#or Self-ins.Lic.#: �J/ G���, /`�`� ,L _ Expiration Date: Job Site Address: �� �`— City/State/Zip:CdTJ�T , N1Lt © i`S�' 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 cer u �er�the pains and penalties.of perjury that the information provided above is true and correct Signature: i�/`�C.�� bate: ] 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#: ACORD,. . CERTIFICATE OF LIABILITY INSURANCE °02/10/2 0) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Joseph MCKeone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE JP tilcKeone Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 333 Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAIC III INSURED Renewal by Andersen INSURER A: Hartford Insurance an J and L Windows,Inc. INSURER B: Nautilus 104 Otis St INSURER C: _ Northborough,MA 01532 INSURER0: I INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR CL POLICY EFFECTIVE POLICY EXPIRATION POLICY NUMBER LIMITS B GEXERALuaslLITY NC958461 10/01/2009 10/01/2010 EACHOCCURRENCE S 1000000 COMMERCIAL GENERAL LIABILITY PREMISES Ea O=umnce $ ED 100,000 CLAIMS MADE' OCCUR MED EXP(Any arse parson) S 5,000 PERSONAL&AOV INJURY $ 1 o0O oO GENERAL AGGREGATE S 2,000,000 GENL AGGPC.94TE LIMIT APPLIES PER: PRODUCTS.COMPIOP AGG S 2.000.0000 POLICY F7 PRO-ECr 7LOC A AUTOMOBILE LIABILITY 35MCC XD 6390 10/01/2009 10/01/2010 COMBINED SINGLE LIMIT $ 1.000.000 ANY AUTO (Eb accident) X ALL OWNEDAUTOS BODILY INJURY SCHEOULEDAUTOS (PerParon) S HIRED AUTOS BODILY INJURY S NON-OWNEDAUTOS (per acci ant) PROPERTY DAMAGE jPer acddent) S OARAOELIABILITY AUTO ONLY•EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESSMABRELLA LIABILITY EACH OCCURRENCE S OCCUR FD CLAIMS MADE AGGREGATE S S DEDUCTIBLE S RETENTION S' S A WORKERS COMPENSATION AND 35 WECPP 1444 02/17/2010 02/17/2011 VVCSTATU• OTH• EMPLOYERS UAB!UrY ANY PROPRIETOR/PARTNER/F.XECUTNE E.L.EACH ACCIDENT S rj00��00 OFFICER/MEMBER EXCLUDED? I E.L.DISEASE•EA EMPLOYEE S 500.000 If yes.describe Wider SPECIAL PROVISIONS below E.L.DISEASE•POLICY LIMIT S 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION INSURED COPY DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR UABGITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR RFpRESENTATWES. AUTHORIZEDREPRESENTATNE `e ACORD 25(2001108) ©ACORD CORPORATION 1988 it R Ic �IC' • •' �`>�.�r�eec�+ �4'J��(V1pylCott�o>iEsFr�me. • . _ ', I Arpj low E f icfure , r =ractor(.EJ. )%f=P. . Solar"H' s'at Cain Coer`cl:ni ® ® UISP(pE5 �'r �i�nitEan-e° • - .s '.5" _Cam•- < - � s :� .. , 2�dmC11bvr 6 tpwbwe./ t+i. fmkif.�nwTn'lu°PBfc�� po �narNy k"F�•b L�o6 plo,Ow1 ' • r.IRI1GmPoo.gppo p6�ew 6.hlfbT•a a e fc.ey�i N.�rearn�et c:aa�'aro abe c.�.proe.!at iho, ... kPRC R6ge Lrolrypmsi�� tf�..ldgd dw4 w1 M11i Alq Lmp itev/PPdu'Itp•bRylr- 'c.�.Ukq.ewuo.c,lor:F-mILI*w:M,Ir.P.P�Vrt�lo+nw�.,4:1t11�°�Pn, . •' - •• '. .4 '• - -�, :,..ram' ;. 't' . , .. - • ., .: , '• •a h�W.l.K'rlfi.C.ti'I'c:Ci)/. bP.L �/r'gAR.R L?IaofdlJ V.dlobw o_p6rcxsvC'b rs/a&dJnRw6.d:.' ' � r . . - �V%.du q�bgoo�dc fsIEF..gE O.6«G6,B•pCQE4y+�f!upW,4e{oryK rk"•gk���6 �-bPf',•oF•a1P .• .. .• •. k r ene wa, mac bYAnidersen. WINDOW REPLACEMENT anAttd�iCaatpaaq i IdralrrtstraI WoodNinyi Composite IF I Dual . Argon Low E Double Hung 100-004145BS-007 ENEREIY PERFORMANCE RATINGS U-Factor(U.S)/I-P So►3r.Heat Gain Coefficient o ADDITIONAL Pec® bE tea tdos�—_ Visible Transmittance Portencturm adpuleWs that lheas mUnps aonfarrn loapplha615 NPRC pro:adutns tar dotartnlninO tvhala product Padaimonsn trg_"Mngs an tlatatrnlnatl tare find aatof ertvOoturiantal a:ndlGans and a apa:ll�ptodu_K NFgC dons 'actulmmandapy Pm0thorpddoas j.,bM an&jnjooO U6 of oey pmdu:lioranybpa:ft6a. . Cansuli tnanufaeWroYs@ataWro f:rotharpmduc(ps4tman:a lnformaUon. vNnt•.nftearg . k t& Tnispmductme�sGi BEY 5sals environmemel standards goveming. J - energy efrlciancy,h a metals in the frame an sash Matedals, �. pact a;qg,and Mmu ^ i education materials. jai i-'i..�-•o,. ;�` DESIGN PRESSURE(PSr7' • A�'��1:. aft ' IuamaWW aWigan �1�I�lUC�IN�I " • IRbA D8 Sloped atll DH IN � 7estdm NAF @mAAMAIpyDVV.MA 101n3lA44O(6. Mnnninctartr stisulntes eoatomumeeto the nonGubL•artndnrds. Maafs otoxemd;N.E,C„Cr�.C,&Le,C.C.Air InOl mUM r quOomants%VDMA Iialh".DodlUeaUon ProOrorn.- . Massachusetts- Department of Public Safety" ' Board of Buildin Regulations and Standards Construction.Supervisor License License: CS 101952 Restricted to: 00' DAVID BANCROFT r 5 JOHNSTON AVENUE WHITINSVILLE, MA 01588 . Expiration: 3/19/2012 ('unun issirrncr Tr#: 101952 ' �/� V10017/I9tOlLl!/6dI.I�Z b�✓�'��LlL6E�6 Office of Consumer Affairs&Business Regulation I 6 OME IMPROVEMENT CONTRACTOR Registrations 601 I Expiratl:III"I - -::—d12 � 51 pnt Card RENEWAL BY AI�IQERSQI >, \ . DAVE BANCR01= ' 104 OTIS STREE- � — NORTHBOROUGH,'N Undersecretary i 1 • i I i - i 010 14:37 15089190903 RBA WM 655 PAGE 02/02 a l4onrd o pd g Reg6l:iaois and S�sdif-414 H =,L �. License or registration valid for Individnl use only bmlt IMIIP��OVEMENT CONTRACTpRi' before the expiration date. If found retura to: Reglst CA\149601 Board of Building Regulations and Standards 010 One Ashburton Place Rm 1301 . ! Boston R.02108 • h _ Diu etnent Card �M ' RENEWAL BY A[� - DAVE A! 104 OTIS STRUT a n • • \ NORTHSOROUGH, Adminlstra cor Not valid w9tt 0t signature 03/31 2010 14:42 15089190903 RBA WM 655 PAGE 02/02 Z. board 0.i�ulldEa4� a Rega7utlu��s oed Sea,dan s4 License or registration Yand for Individ'C use only HOMEE IMqPR+`+O1/EMEt�'f ON ement CardTRgCTOIp' ' before the expiration date. If found return to: ! R®glstraliana,149801 Board Of Building Regulations and Stwdards 010 Ope Ashburton Placo 1301 ' ^el ' Boston,lea.02108 RENEWAL BY ARD •�— 104 OTIS STRE:ET �� NORTHBOROUGK MA $32 A dminRat-a„fir Not valid without signature'gnature 1 Engineering Dept. (3rd floor) Map Parcel ( �� "-kermit# (v r t. House# Date Issued (n _,Z(o �91a 1 Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) CP3F (lee 7 7 Sd Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) ,„ �' c�.�` �� r Planning Dept. (1st floor/School Admin. Bldg.) Defini ' e n Approved by Planning Board 19 BARNSTABLE„• _ 1 MASS, TOWN OF BARNSTABLE Building Permit Application Proj et Address Village &4�f l�� Owner Address Ql,a ,n, arwf T�C�'� Telephone — 9 Permit Request �F,i�ID. lv� ` Vic`g,(ki) / �f/,lGr�(o it/ �� C'ii. 4bp JS/lFky S/ac- Ar 9 w o a e(zs W,#//l WAV 6 ' o — Ra':Cr964- E ",/Sl INK, /V 7 pmfi Mew irY�iC L ,C-V5-r1 fS/T. W v Wll avl epma• "A-le zolLws ss jTy ^ 6 to f46 1,"-k Plan/ First Floor _/f�`-CJ square feet Second Floor /� � square feet Construction Type Estimated Project Cost $ Zoning District tF o�E. Flood Plain /0 Water Protection Lot Size ;-, Rao 12 Grandfathered 4Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes JkNo On Old King's Highway ❑Yes �dNo Basement Type: XFull ❑Crawl ;&alkout ❑Other ' Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing C� New Half: Existing New No.of Bedrooms: Existing 8 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 INew Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Numberc6a6 Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTI G FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE 5 BUILDING PERMIT DENIE FOR THE FOLLOWING REASON(S) ' �• .J 1 1 �J • 1 � ,' �,)� t, � �'�+��`:.' a.�' � ���• 1� .. .� « ti �+ ,1 tiff .tn .1. y i r i Tr uISEN& =IBM No ram: P+ Im EMEEMEM PAIIAM ■HIM■0 5.1 3 F 91n*EN RD IV lFsoai: • `. .as': '� .vat',p!`r .� �+" In' I,X`�� I �€�� '.ia Z♦ .�_.�,"�_ �e'a'` .1�a���q�.YP RV1r1d���.i�g1� EMO- MEW III JS a tUL ;L-ffl gg��um- ,�wAT-m, Womm�,,r Eys, ���� - •� 1 ' `� a � , k fit;INS :• --ll' 7 a *,`X,EN Uld z `i IMAM1 s�� YY I� � jy `�{� W 1 `\1 > ` `►. 1 c�-L 34,'r �::0 ■■■■■■■■■■■■®® ®®■®®®■■®® IMEMOMMEME ■■■■■ ✓ ■���■t-� pia■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ IMMINIMISIMENIMME■■■■.r■■■■ S ■■■■■■■■■■■■■■■■■■ ■■ ME■■■■■■■■■W■■■mmI■■ ■ : , - ■■■■■■■■■■■ ■■M■■■■■■■■■■■ ■■ _ . . ■■■■■■■■■M■■■ ■■■■ ■■■■■■■■■■■■■■■■MICE MOON I rWAVAA ' ■■■■■■■■■�■■■� ■ENM■■■■■■■■U■■■ • • d jPm. - ' . ■■■■■■■■N■■EM MIM ■■■■■■■■■ l■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■E■M■■■■ ■■■■■■■SI Go ■B MM■ ■� NOON■■®®■■ NEON . �,i■sip®i�E�i�Ee� ,� „ ■■■■m ■■■■�.r! \,,il■■II■I■Ill®I�i, 5s ■■oomm mom■/�i1►\ it■111■I■111■1/� sommmmomom ■■■■■//,I►.`;.�i\Eli■111■I■111®!■%■ 1:1■®■■■■■■■ SENSE 11°.'®►�.�`!INEII■I®111®1 %� ■®■■■■■■■ ■■1■ENi���Ii■ �iiii�i■'ili®!®il�i��il�lll ■■■■■®®®® ■EIIIIiI■111■I■II■■II■I■111■I®II■111®1111■®■■■■■■■■ ■■Illill■111■I■II■EIIEI■1!1■I■II■111®i 111■■■■■■■■■ E■■IIIIII�III■I■II■■II■I■111■I®II■111■1 III®®NOON■■® �ElIlI11E111■I■II■■II■I■111■I®II■111■IIII®®■■■■■■■■ ■i■IIIII®111EI■II■■il■�I■111■I■II■lil®i��ll; ■■ME ■■■IIIIf■111EI■II■■II■'I■ill■I■II■111■11lI®��� NOON ■■■II1111EIlt■IEIIE■II■�I■111■I■II■111■1111% `;�■■■■■ ■■III I■111EI■II■■II■I■111EI■II®111■IIIII�..//®®��®l1■■■®■ ■�li ICI■ll■tll■`I��II�i®II�II.II�III// I, 'kill m= ■■�■■■,�■■��®ice Bill■■■■ ERE a ' 11 ME I■E■■■Oil■�■■■■■ill■Iill1■IIIII■■■■ i � - = ■■■ 11■I®III®IIIII■■® oEE■■■E■■E II I■IEIII■IIIIIEWI■ • . = NONE■ 111■1■III■IIIII■ ■ ■■E■■EME 111010111111111E ■ NNNN■1■NNEONN■■ii■■�i®1■111111111■■■■■ • ' '■E■■■E REI®IIIIIIIIINME■ SEEMEMIMMISISM r ■■■Q!MMU I■III■II■1■E■E■ ■■N■E■ IME■EWE? ■■INil■111■IIIII■■■■ y - ■■■E■�■!1■II■IIIIIIIII■■■■ m- m . _; ; ..; t _ .. ■■■E■■�■11lNl111111011 ■■ ■■■■E■E"m" mm= SOMEONE I The Town of Barnstable • s�xsTas�. �0� Department of Health Safety and Environmental Services i0t� 9- Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: i1�f� Est.Cost o� U(J� I • Address of Work: J� w 1 Owner's Name f r Date of Permit Application: N:2 AA e — I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERNUT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME MROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the o t Date Contractor a Registration No. OR Date Owner's Name L The Commonwealth of Massachusetts I Department of Industrial Accidents � -�_ -= OfltC9o/IniveSdgatioils 600 Washington Street ��.• Boston,Mass. 02111 . Workers' Compensation Insurance Affidavit WOW 1pGation- Cil • [� / hr �J Q 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity ❑ I am an employer providing workers' compensation for my employees working on this job. �` rampany name* a1I,�lress: • .. .. .:. .. city- tice UNISMM olio'# p I am a sole proprietor,general contractor,or homeowner(cire'le one)and have hired the contractors listed below who have the following,workers' compensation polices: fees:. .: 1DStlrBtice eo. .. • . . . •policy�i.. .. tpin►an I Murance co. polll.Y# "ilure to secure coverage as required nuder Section ZSA of hiG t.152 can lead to lase itnpositioo of criminal penalties of a flue up to$1,.5U0.00 aadlor noe yea 'imprisonment as wdl as civil prnattic5 in the form of a STOP WORK ORDER and a tine of S1U0.00 a day against me. i understand that a copy Of rsIltis statcmertt tray be forwarded to the t)lTte of JavcstiAatinns of lbe D1A for eovernge verificatipn. I do lietehy terrify unde. he pains mzd pe ' oofFe►jjuury that the iuformrrtion provided above is due and corrw. Signature - ' <� arc �C44-t.e- S z Print numc Phcnc# t:5 ---115 Egg orrki:d use only do not waste In this area to be completed by city or to otfici>al city or towu; periniUlicense q Building Department OF iCeneiah Board Q check aimmediate response is required OSclectmen's Mice Health Department contact person: phone tl; �_�Other (mined.1 94 I')A! i ._ Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation:for their employees. As quoted from the "law",an employee is defined as every person in the service of another imd"e`r any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership,association,corporation or other legal entity,or any two or more of the Coregoing en-aged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual ,partnership,association or other legal entity,employing employees. However the 'owner of a dwe'lliiig"house having not more than three apartments and who resi.des"therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. IvTOL chapter 152 section 25 also states that every state.or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business 6r to construct buildings in the eomtnunwcalth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying companv names,address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the cite or town that the application for the perm it or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at 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 fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call.. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of levestigauons 600 Washington Street Boston,Ma. 02111 fax N: (617)727-7749 phone#{: (617) 727-4900 ext.406,409 or 375 � r gyp\ ✓11B V!(L771.1)t4/YlI:RCLGIiI, O`�.�Ul.!A,O:IGA:IlIJQCCJ 1i. Restricted To: 00 DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE 08 - None 5 0 9 3 9 it Number: Expires: 16 - 1 & 2 Family Homes Restricted To: 00 Failure to possess a current edition of the Massachusetts State 8uiilding Code je J GEORGE R NICKERSON is cause for revocation of this lic se. 89 TEATICKET PATH E FALMOUTH, MA 02536 HOME IMPROVEMENT CONTRACTOR Registration 101510 Type - INDIVIDUAL Expiration 06/26/98 GEORGE R. NICKERSON G� Go 89 Teaticket Path .Falmouth MA 02536 ADMINISTRATOR N (1 r---=------=-----.=— ------------------ -------- II I I rn � ii I j1 -4 rn l X Z O i i �Z � �� i � � i • � II M Z II ^ I I - I1. ------- ------------------- II II 11-- v II WINDO T.�<11 I , II ----------------- it -70 ' I WINDO T, t• rnDp z�u rn o , i II it II , I II - Z< I 4� WINDO T.ME. � I1 II it II I I , II 1 , p . 1.• .Z 1 I I I �--- ------ _ I1 »-. I,U ADS* NEW DORMER PLANS FOR THE MG WRE RESIDENCE :�,�-. {�,,,.1 �� A�wom :a: a ARCHITECTURAL DESIGN SOLUTIONS !!! 111 11 BAY ROAD CATUIT, MA w..eba� to ar. tlr a!N d peadwat maehpee, ma eel-508-477-8930 - • _ owwr� capehouaeplans®aol.com ce11- 774-487-0093 SECOND FLOOR PLAN 6v N'd«um Au'a W90.. . r .r EXISTING RIDGE NEW DORMER . EXISTING DORMER 1 3/4 X 9 1/2 LVL _ U) M 0% rn.o ALL'.NEW ARCH: TO BE '515TERED A5PHALT.5HINGLES ALONG EXISTING` 0 — m i/2°GDX'PLYWOOD 2XS.GEILING-JOISTS � a 2X85®.16'O.C.. ] ao p r w u ------ CORNICE DETAIL __-- ~� ----- = z TO MATCH OPPO51TE EXI5TING DORMER W i. 1/2' GYP.BD. 4 �; IX3 STRAPPING r I EXI5TIN6 TO REMAIN r 0 EXISTING:FLOOR TO: BE PATGHED'AS NEEDED W m m AND NEW'FINISHED POOR I" u I' MATCH EXISTING U EXISTING 2XIOS !--------i m I 3 EXISTNG 5TAIR5-�-------- s €fi � .. BEYOND i-------- . . 3a Sr ' a a I 3 � r W r r-------- I . EXISTING 2XI05 F-------- IL r-------- z -------- �jJ W� . I. ALL DIMENSIONS TO BE. VERIFIED IN FIELD:ANY 015CREPANCIES TO BE" N BROUGHT+TO ATTENTION Of THE l 5EGTt0N • I TO GONSTRUGTIWNER PRIOR 5GALE 1 / 4 1 ' — O " +/— (00 NOT 5GALE). i i Revisions: 1 DATE DESCRIPTION ` , I 1 �fi 1, �EAL I ���: LOCUS CUS OWNER: JAMES F. MAGUIRE BK. 2479 PG. 29 CUS IS SHOWN AS LOT 23, MAP 7 OF THE WN GE BARNSTABLE ASSESSORS MAPS. References-: �cale:l��2063' NCHMARK: TOP FLANGE BOLT ON HYDRANT (ADJACENT TO WORK OPEN), PLAN BOOK 132 PAGE 143 LOCATED NEAR INTERSECTION OF FULLER MARSH ROAD AND Locus M p PLAN BOOK 19 PAGE 143 PINE RDIGE ROAD, ON EAST.SIDE OF FULLER MARSH ROAD PLAN BOOK 94 PAGE 47 AND SOUTH OF PINE RIDGE ROAD. ELEVATION 31.f7' N.G.V.D. ZONING DI IBIQT ED SITE PLAN BY LANI? PLANNING INC, DATED FEB. 16, 1996. MIN. AREA 43,560 S.F. MIN. FRONTAGE 150' FRONT YARD 30' SIDE YARD 15' REAR YARD 15` FLOOD ZONE A TO EL. 11 FLOOD ZONE C ABOVE EL 11 Project Title: ff PERMIT L..A IV MAP 7 PARCE . 23 BAY HOALJ ,IN Cu` TUI T MA PREPARE} FOR: I JAMES F. MAGURE REALTY TRUST 911 Matn Street Oaterville, MA —" 02655 \ 1 A. M. Wilson Associates'.Inc. 508 428 1450 f FAX 420 18.56 Drawing Title M: 7 L: 2. J N/F - JEFFREY P. & NANCY.S. LOWERY 1 � i Wetlands . Permit Cb Plan 721 721 it i91 - \, \moo �� Scale: 1 =20' 0 200 50 FEET Date. Mar. 16, 1996 Dwg No: Field: Design. A.M.W- Check: C.P.J- G Drawn: J V 8 ob No: 2 0794.0 Sheet 1 of 1 � r e F � f i ' / / 1 AL CO ( ! ( IL 1 ' BAY AL 1 q ( 1 1 �1 I jl - 1 POPONESSETT -� BAY iL R�,GE TY f ' \ ZRSW AL ' 0052,500 t S.F. `y �J 7\ 00 ID col- I OD _ 061, 16 G \ IVA 12 JIL / 76AL OR _ 22 / 1 \ �-------------- .�� IAD ;r 28 _ 32