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0072 BOB WHITE RUN
�� Gai le 1�� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 2 Parcel T(TApplication # 20 561 Health Division r' ^ j 3R {^,: �; 'Date Issued S Conservation Division Application Fee " Planning Dept. Permit Fee 3 ' IT Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village Owner�ah 3 149 AOzW, Address--3a !?�Ob Npl�V%N yt_ � 1 Telephone'�_�' Permit Request _ S ��/`� 0KQ_ /oo Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new� �y Zoning District Flood Plain Groundwater Overlay Project Valuation '"1 J Construction TypeIMIfJ \— 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 King's 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 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: Zoning Board of Appeals Authorization ❑ Appeal # Recorded (J Commercial ❑Yes )kNo If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number Address U M l--j y g— V"ZJ_ License # ILL`— Home Improvement Contractor# �U—1 Email U�. ✓Worker's Compensation # Iyv ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �];J �n► Sao ���r i 6�o T M JFA M �k U Qv�l Iv�P 13 -SIGNATURE �// � DATE � ' � FOR'OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER ' ' DATE OF INSPECTION: FOUNDATION , FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ' - p 3 PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ' FINAL BUILDING DATE CLOSED OUT x' ASSOCIATION PLAN NO. 4 f .:own of Barnstable Regulatory Services _IP?=AB' Richsrd V.Scali,Director bMS'7^ 3 . ,0$ Building Division Torn Ferry,Building Currunissioner 200'lvlaiu Street,Hyaruris,.n4A 02601 www.town.barnstable_ma.us Office: 508-8624038 Fax: 508-790-6230 ProperLy Owner Mus t aaiplete. and sign ':i his Section If Using A$uilder as 0n'ner of the subject propen:y hembyauthoIU'le _ `i a - -� _ C\\/'� co acr on nwbehalf, i.n all.matters rclativcc t"o \*ror-.auth��rizr8 this hull ina pc_3zni lic,.tion for: 1�e _.� (Address of:jobY Pool fences and alums aire the resporl_5ihility of±e applicant. Pools are of to be filled or uxiLed IwJore fence is i.n_tita]Iecl and all [u�al js�specuons arp. perftu-r ed and acc:cpt:ed- Sit natwe of Owner Siguaturf. of Applicaj)t Prnt Nan- Print.Narrx-: Date ��:=ORAIS:O��'E12P�F�.iltiS10NP(X.)Lti I Federal ID 9 05-0405629 RISC Cn„ineering RI Contractor Registration No 8186 MA Contractor Registration No 120979 A division of I'hielsch Engincerin" CT Contractor Registration No 620120 ' 5 Dupont Avenue.South 1`nrmouUl.1LA 02664 CONTRACT 508-568-1926\-6197 FAX 508-568-1933 Page 1 R I S E PROGRAN•1 THIS CONTRACT IS ENrEREO INTO BETWEEN RISE. ENGINEERING C I L-IRC•S ENGINEERING AND THE CUSTOMER FOR WORN AS DESCRIBED BELOW CUSTOMER PHONE DATE CLIENT]) WORK.ORDER Janice IM Valente (508)962-2078 09103f201 S 198840 00002 SERVICE STREET BILLING STREET 72 Bob White Run 72 Bob while Rim SERVICE CITY,STATE,ZIP BILUNG CITY.STATE,ZIP ' C..oltttt. MA 02635 COtUIt. MA 026J- JOB DESCRIPTION BARRllilt:We have discovered What appeals to he a mold!mildew-like substance in your holnc.This is built,hrou2ht to •our attention to idcntit'v it as a pre-csistine condition to the insulation and air scaling work planned fir vouT home. Your si,,nature is your acknnw Icd4crnem of these c•ondilions;Ind agreement to proceed.•there arc signs of blackening,on(he underside of the roof shcalhine in the attic it appcalrs h)have beat caused by the lack ul•proper ventilation()vets mane\-cars. s0.00 AIR SEALING:Prvide labor and materials tq seal areas ol•vuur home against LvastefuL excess air leakage. This work will he performed in concert with the use ofspecial owls and diagnostic tests as assure that your home will be lei with a healthful level of air exchange and indoor;air quality.N-latcrials to be used to seal your home can include caulks.to:nT,rkeatherstripping and other products. Primary areas fur scaling include air leakage to allies.bascments,attached garages and other unheated areas(windows arc not generally addressed.) (16)working hours. A reduction in cubic feel per minute(cfin)of air infilimliou Will occur.but tic actual number of cfn'I is not guaranteed. S 1232.00 ATTIC FLAT:Provide labor and materials it,install a 6"layer ol•R-22 Class I Cellulose adduct III(400)square Icel of Iloi,rcd attic space. $792.00 DAN•1NIING•Provide Labor and materials to install a 12"layer of R-18 unraced fiberelass halls In(2qU)square feet lox d;unnlim, pu rpoCe,, y _ 5512.;0 A•I HC''FLAT:Provide labor and materials io install a 12"layer ill•R-42 Class I Cellulose added to(I350)square fret of open attic space. S 1.971.00 S'I.ORAGF BARRIER:Homeowner is responsible for the removal ofthe stored items blocking the insiallmion ufwcathcrizalion work in the attic. Removal must occur prior io the scheduled work sLuL S(I.00 X17R,-AC'C,Fss:Provide labor and materials to install(1) cusily Tnoved.insulating cover for the attic access li)lding stair. The cover has integral weather-stripping to restrict air leakage. S230.19 VENTILATION:Provide labor and nialeriuls to install(4)8"diameter roof vents)to increase ventilation in attic;areas. The vcnf can be supplied in(circle color)black,brown.gray or mill finish. ;;348.60 VENTILATION:Provide labor and materials n1 install(1)insulated exhaust hose to esisling hauhr'oonl fail(..,). s>(t.00 VENTILATION:Pmvidc labor and materials to install ventilation chutes in(100)railer hays to maintain air Ilow•. S:49.(i0 COMMON WALLS:1'mvide labor and materials to install blew])in Class I Cellulose it,(2.24)mlimrc Icc(of•r common wall through a])interior surface drill and plug inctho(1. Plugs will he simckled and tell in a relatively smooth eonclitiim.finish sanding:nut touch-up priming/paiming will be the ciisiomer's responsibilite. 51111.40 Federal ID#05'-0405629 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120979 A Aiwisiun or'1'hicisch Engineering CT Contractor Registration No.620120 i Dupont Avenue.tinuih Ynrmnuth,NIA 02664 CONTRACT 5OH-568-1926 X-6197 FAS 508-568-1933• I S .E PRQGRAN-I Page 2 THIS CONTRACT IS ENTERED INTO BETWEEN RISE ENGINE£RING C LC-R(.S ENGINEERING AND THE CUSTOMER FOR WORN AS DESCRIBED BELOW CUSTOMER PHONE DATE CLIENT a %YORH ORDER Janice N4 Valente (508)962-2078 09/03/201 i 1988110 00002 SERVICE STREET BILLNG STREET 72 Bob While Run 72 Bob-White IZun SERVICE CITY,STATE,ZIP BILLING CIrY,STALE.Z;P Cotuit. MA 026;5 Cotuit. IN1A 02635 JOB DESCRIPTION GARAGE CIal-ING:Provide labor and materials to install 12"R-44 densely packed Class I C'CIIUIOSC insulnlion to(660)square feet of garage ceiling Luc;ucd below a huffled Hoof wen.by drilling limes in the ceiling from below. I lolcs drilled will be plugge(l. Plug:will he spackled and tell in a Iulf lively smooth condiliun.Finish sanding and touch-up pritninJpaiulinIt will be life cuslinlcr'S responsibiliq. SI.QO>.ti0 INCENTIVE:111SE Engineering will appl%.all applicable.eligible incentives to this contract. )'oil will he billed only the 1\1el:1 flit)Unt. Currently,tin eligible nicasures.the Cape Light Compact olTcr.75%incentive,nil Iu exceed S4,000 per calendar year.and an incentive of 100%ITN the Air Scaling measure;. For the safety and health conducting home's indotlr air quality,we will be conductin a blower door diagnostic of the available air flow in your home hoth before life work is begun.and tiller the weatheriiation work is complete.We will also conduct if Full;fssessnlent of life Combusliin safety of your healing syslenl and water healer.This has a value ofS90 and is aI no cu:I to you. S90.00 Total: $7,395.49 Program Incentive: $5,232.00 Customer Total: $2,163.49 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Two Thousand One Hundred Sixty-Three & 491100 Dollars $2 163.49 UPOtl FINAL INSPECTIOtf AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.INTEREST OF 1%VALL BE CHARGED MONTHLY ON ANY UNPAID BALANCE.AFTER 70 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES.RIGHTS OF RECIS ?SCHEDULING,AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE�Alr BLANK SPACES 1 AUTHORIZED SIGNATURE-RISE fr EnnlneurinD CUSTOMER ACCEPT:JdCE `�/ ✓ �. NOTE:IIUS CON<AC i'MAY BE VlI iIIDRAWN BY US IF NOT EXECUTED WITI II,V -A J DATE OF ACCEPTANCE 30 ACCEPTANCE OF CONTRACT-'THE A13OVE PRICES,SPECIFICATIONS AND CONDITIONS ARE DAYS. SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO nIE WORK AS SPECIFIED.PAYMENT WILL BE.MADE.AS OUTLINED ABOVE i The Commonwealth of Massachusetts Department of Indumial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 w%w.nuw.gov/dia I3'orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(BusineWOrganization/Individual):Insulate 2 Save, Inc Address:410 Grove Street City/State/Zip:Fall River, MA 02720 Phone#:508-567-6706 Are you an employer?Check the appropriate box: Type of project(required): l.O[am a employer with 20 employees(full and/or part-time)." 7. New construction 201 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.(No workers'comp.insurance required.] 3.D I am a homeowner doingall work myself 4. ❑Demolition y [No workers'comp.insurance required.]r 4.[]I am a homeowner and will be hiring contractors to conduct all work on my property ro 10 0 Building addition . I will ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.D.Otherinsulation 152,§1(4),and we have no employees.(No workers'comp.insurance required.] ::*Any applicant that checks box#1 must also fill out the section below showing their-workers'compensation policy information. it 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.. -lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site -information. -Insurance Company Name:Liberty Mutual Insurance 'Policy#or Self-ins. Lic.#:XWS 56418741 Expiration Date:. 12110/15 Job Site Address: V_t /n City/State/Zip: Attach a copy of the workers'compensation policy decla ration nppaaiee(showing the policy number.and ezpira on date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance :coverage verification. 1 do hereby certify under the pains and penahies of perjury that the information provided above is true and correct Si nature: Date: 'Phone#:5087567-6706 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#: ,�►��® CERTIFICATE TIFICATE OF LIABILITY INSURANCE THIS mwnRwE E ISSUED AS A MIATTBt OF ORMIATION ONLY AND CONFERS NO RIGHTS 12/9 14 F7CIC7E D08S NOT AF�ifAfiVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFEORDED BY THE L P�pli� BE-CW-` TMS Ci MVICATE OF NGURAMM DOES NOT CONSTITUTE A CONTRACT BETWEEN THE LSSUING 1IrS REBEIiRATiVE OR PROOtJ>CER MID?HE CERTIFICATE HOLDER. URER(S), AUrFIDRIZED � � h ��'ADD ,the olic IeS must be endorsed. N S I the tlwow and eanditmw of the P •� ) A O IS W sub"to ' �policies rmy require an endorsement. A statement on this certificM does not confer ruts:to the holiWr in Yiu of such eMers@Wn S). PROGUM CONTA T j AathoaY F. Co_sdeiro Insurance Nar�E: _ 171 Pleasant Street PHONE 1508) 677-0407 _ FIX N (508) 677.-0409 Fall River, MA 02721 Ao6DREss: hsouza@cordeiroinsurance.com --- INsuREt+rs)A&FORDINGCOVERAGE NAIC1 yiqLaw INSURER A:Liberty Mutual Insurance --- -�- Insulate 2 Save, Inc. INSURER B` 410 Grove St. INSURERc - ---... Fall lZit►6S, MA02720 IN6URER 0:_ INSURER E: COVWtA4E8 INSURERF: __.....-- .--- CERTIFICATE NUMBER: REVISION NUMBER: THIS IS 14 CERTIFY THAT THE POLICES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE I INDICATED. NOTWRHSTANDNG ANY r- INSURED NAMED ABOVE FOR THE POLICY PERIOD CERTFIOATE.MAY BE ISSUED OR MAY����'��OR CONDIT ON OF ANY COI.I RACT OR OTHER DOCUMENT PD WITH RESPECT TO WHICH THIS E UCIE THE INSURANCE AFFORDED BY TI-E POUCIES.DESCRIBED HEREIN IS SUBJECT TO ALL THE ICRMS, I LUSIONS AND OF SUCH POUGES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPiOIF WiYRANaE I POUCY NULBER i aMlaD - I p A a�O1LUAae11Y Y I Y IMM 56418741 12/io/14: 12/10/15' uLRrs EACH OCCURRENCE 5 1.,.000 OQO Ir X. nE CRCu�LGEN:t vTY s 30 000 L r ii CIAKSMADE ? X OCCUR )- I I NED (A are Parsm) S 5 0 PERSON%LSADVINJURY :sI,OQ p 000 C^E'tfLl�3CaREipATELiiTAPP( SPER GENEAaLAGGREGgTE i S 2.00O.00O I ICY PRO. ' LOC PRODUCrS-OOW* AGG i S 2 OOD O A AUTOUOaA E UAa111M 5 t IBAA 56418741 12/10/141 12/10/1's R s 1.00'0 ANY AUTO kLOWNED S�(A,Ep I SODILY INJURY(Per.persor) I s OS X AUTOS I 1 SODILY INJURY(Par acodar*i s X HtftEDAIrTOS X AUT ED ;(ParaerJerlt� 5- i A X UOMLLA LOB I�X OCCUR Y Y 1USO 56418741 12/10/14; 12/10/151 EACH OCCURRENCE S 2,000,000 E1)CHIS8 UAB i GAiIASiMDE — i AGGREGATE :s TO,000 A aO ----- �XWS 56418741 12/10/14 12/10/15 X: WCSTATU- ' OTII•' i AND UANUTY Y I N —SDRv I Iu2c:. FR _. )jL/dr11�E7�Q1TAlE �IN/A' _E_L 9•x- AgP-ENT.__. S .--SOOL000 q un0er" _E.L DISEASE-EA SAPLOYEE:S_500,000 N'CF OPEPATIONS OeIvw I EL.DISEASE-PQWCY Lr,1rr 5 500,000 i • DESCFAFn*OF OPEPATIOW I L.00A710M I VENCLES(Atdeh ACORD 101,A4200"Re—rks Sahedwe,it more spate Is regdmd) ' Proof bf Insurance. . I I I TW*ATE MOLDER CANCELLATION SHOULD ANY OF THE ASOVE DESCRIBED POUCI S BE CA14CELLEDSEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 8E DELIVERED IN ACCORDANCE'AnTH THE POLICY'PROVIW"S. ' I I AUTMORRED REPRESENTATIVEc',/ae�`�✓ �� I I ©198E,2010-ACORD CORPORATION. All rightisreaervod. ACORD6(2010/06) The ACORD name and logo are registered marks of ACORD Phnr1P Fax: E-Maii: Office of Consumer Affairs and Business Regulation - 10 Park Plaza - Suite 5170 Boston, Massach> etts 02116 Home Improvement Cdhtractor Registration -_: 4 := =�_. Registration: 180747 =�=- Type: Corporation ` F Y = Expiration: 12/29/2016 Tr# 261507 INSULATE 2 SAVE , INC. £. ROLAND LANGEVIN =` .............. ...............- ......... 410 GROVE ST ................... ..... ............... _-_..._.____ .......... ...... . . .�... ...__._.^.......... II FALLRIVER, MA 02720 _.._ Update Address and return card.Mark reason for change. SCA, c, 20M-05n1 � � � � ' Address - Renewal Employment Lost Card Office of Consumer Affairs&Business Regulation License or registration valid for individul use only 440ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: h teglstration: I.80747 Type: Office of Consumer Affairs and Business Regulation . =1?Expiration: to /2016 Corporation 10 Park Plaza-Suite 5170 .y Boston,MA 02116 INSULATE 2 SAVE',ING:--.:.. .,, ROLAND LANGEVIN.-; 410 GROVE ST FALLRIVER,MA 02720 _..... .. .— -..:---...._.._.............................._.._. undersecretary Not valid without signature Massachusetts Department of" P�. Board of Buildingublic Safety - Regulations and Standards License: CS-103861 Construction Supervisor ROLAND LANGEVIN 56 HIGHCREST ROADr= FALL RIVER MA 0271 Commissioner Expiration: 0 8124/2 0 1 7 i Town of Barnstable *Permit# Expires 6 months from issu date Regulatory Services Fee .D s�erna>�, 9 MAS& Thomas F. Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Map/parcel Number o 5-0 NotValid without Red X-Press Imprint Property Address 72- Sob (, 4.4� O ws) Residential Value of Work$ /0/ 17 B'0 a Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address '_T,�-Q.N ly,S 4- �Gt,n�t 2 �� I e N 7 e_ Contractor's Name S64U4-N 1J E, (W aw5 r7an1 vvi5 Telephone Number Y d/ Home Improvement Contractor License# (if applicable)p l 7-3 ys Em Construction Supervisor's License# (if applicable) / s 7 / QWorkman's Compensation Insurance AUG - 9 2013 Check one: ❑ I am a sole proprietor ❑ I am the Homeowner TOWN OF BARNSTABLE [71 have Worker's Compensation Insurance Insurance Company NameA-�—q CO - Workman's Comp.Policy# ,�I C, l a 76 9? 3 Sa 3 l y Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) [e-side Replacement Windows/doors/sliders.U-Value 0, 3 D (maximum.35)#of windows `J #of doors:_L_ ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. s 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. �e SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\8R76BDVA\EXPRFSS.doc Revised 061313 Southern New England Windows d.b.a Renewal by Andersen of SNE Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen kor d License: CS-095707 w BRIAN D DENMSON '` 1+ 7 LAMBS POND EIRCLL ll s Charlton MA ID1507 t Expiration Commissioner 09/08/2014 Office of Consumer A airs n Business egu anon 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL Esmiration: 9/19/2014 DENNISON BRIAN 1137 PARK EAST DRIVE WOONSOCKET,RI 02895 Update Address and min no card.Mark reason for change: �,G 2ou-W O Address O Renewal O Employment 0 Lost Card ke afConsomer Alf 1n&Badness Rrpbtioa License or registration valid for IndNldul use only ME IMPROVEMENT CONTRACTOR before the expiration date If found return to: Office of Consumer Again and Business Regulation UNI -Expiration: egistration: t73245 Type: 10 Park Plan-Suite5170 9H92014 Supplemenl:7ard Boston,MA 02116 SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL BY ANDERSON- l� DENNI BRIAN 1137 PARK FAST DRIVE WOONSOCKE'T.RI 02895 Uoders .M y Not valid without signature - Print Form 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 N1ITle(Business/Organization/Individual): Y," e r 1i Akw Lgla,,� f;Au/g uG Address: 41416,61 ko,4,6 City/State/Zip: L 1/c_o IN Phone#: �-�O l �a� — 800 Are you an employer?Check the appropriate box: Type of project(required): 1.EWI am a employer with ;t D 4. ❑ I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. El 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 . 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp. insurance.: 9. ❑ Building addition required.) 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12. of repairs insurance required.]t c. 152, §1(4),and we have no ,_�'D / employees. [No workers' 13.92J Other Cc,I ee�t' comp. insurance required.] *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating They am 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: r4,V 4f /om Policy#or Self-ins.Lic.#: 76 [ 9 3,5-02.3 I y Expiration Date: 9 .3 Job Site Address: Igo 6 �,('h c`� V/J —City/State/Zip:p -� i ✓�. o�G �S Ci /State/Zi : o v i 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 cerdbuw&the airs and enaldes o e 'u that the in ormation provided above is true and correct Siena : .. Date . 87 � 3 Phone#: ?,ROD ,n 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#: Client#:30124 SOUTNEW ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 5/08/2013 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 Anita Little NAME: Willis of New Jersey,Inc. PHONE FAX A/C No Ext:856 914-4660 AIC,No): 856 914-1881 1015 Briggs Road ARE Anita.Little@willis.com PO Box 5005 INSURER(S)AFFORDING COVERAGE NAIC# Mount Laurel,NJ 08054 INSURER A:Selective Insurance Co of the S 39926 INSURED INSURER B:Argonaut Insurance Co. 19801 Southern New England Windows LLC INSURER c:Beacon Mutual Ins.Co. 24017 D/B/A Renewal by Andersen INSURER D: 26 Albion Road INSURER E: Lincoln,RI 02865 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 CONTRACTOR 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DDIYYYY MM/DD/YYYY A GENERAL LIABILITY S202945900 8/10/2012 08/10/2013 EACH OCCURRENCE $1,000,000 li:701M MERCIAL GENERAL LIABILITY PREMISES ERENTED Eo Tu ence S 5O 000 CLAIMS-MADE �OCCUR MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE 52,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000 POLICY jE�07 LOC S A AUTOMOBILE LIABILITY S202945900 8/10/2012 08/10/2013 COMBINED SINGLE LIMIT COMBINED $1,000,000 X ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) S X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE S AUTOS Per accident S A X UMBRELLA LIAB OCCUR S202945900 8/10/2012 08/10/2013 EACH OCCURRENCE S5,000,000 EXCESS LIAB HCLAIMS-MADE AGGREGATE SS OOO OOO DED RETENTIONS S B WORKERS COMPENSATION AIC927698352394 8/21/2012 08/21/2013 WCSTATU- OTH- AND EMPLOYERS'LIABILITYTORY C ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N 6802$ 8/21/2012 08/21/2013 E.L.EACH ACCIDENT S1,000,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION Southern NE LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 26 Albion Road ACCORDANCE WITH THE POLICY PROVISIONS. Lincoln,RI 02865 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S214638/M214631 AXL Renewal BIiceens m 173241 RENEWAL BY ANDERSEN r 1ctn'C#1742 ' • Andersen. CT License#Or.34SSt WINDOW REPLACEMENT .nMdm,m(ompn, 26 Albion Road • Lincoln,RI(12865 Lwd firm#1M Phone 866.563.2235•Fax 401.633.6602 Federal Tax ID#4r.05AAG3l Southern New Eneand Windows,LLC d/b/a Renewal by Andersen of Southern New England CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(L Name DateofAgreement Buyer(s)Street Address.City.Siam and Zip Code/P.O.Box �- L L' o4a tl t MA. O Z 6 3 s E-Phll Address Home Telephone Number WoritTelaphone Number Q-,r 0--1-11 M t, C-0^ - ti29, 06a.3 P& -V •A0V Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal by Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheel(s)(collectively,this'Agreement"). ❑Historic ❑ Condo ❑HOA7 Total Job Amount_/ T f 6 Estimated Starting Date: Method of Payment ❑Check ❑Cash O Financed Deposit Received(33%): 3 �Q� -ra 6 GJKs Credit Cards are accepted for deposit only-maximum 113 of the Balance at Start of Job(33%): t_ V project cost(Plate see see Credit Cord Payment fgrn.)By signing this Estimated Completion Dace: Agreement you acknowledge that the Balance at Start of Job and the Balance on Substantial (�D 0 • / Balance on Substantial Completion of Job cannot be made by credit Completion of Job(33%): tJT 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 any of the terms of this Agreement.Buyer(s) acknowledges that Buyer(s) (1)has read this Agreement,understands the terms of this Agreement, and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date firstwritten above and(2)was orally unformed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (Rhode Island Sales Only)Notice to Buyer:(1)Do not sign this Agreement if any of the spaces intended for the agreed terms to the extent of then available information are left blank.(2)You are entitled to a copy of this Agreement at the time you sign it.(3)You may at any time pay off the fall unpaid balance due under this Agreement,and in so doing you may he entitled to receive a partial rebate of the finance and insurance charges.(4)The seller has no right to unlawfully enter your premises or commit any breach of the peace to repossess goods purchased under this Agreement.(5)You may cancel this Agreement if it has not been signed at the main office or a branch office of the seller,provided you notify the seller at his or her main office or branch office shown in the Agreement by registered or certified mail,which shall be posted not later than midnight of the thirdcleudma do;�aftoa.the da-y-VH&wh5e]6&c haryersigawth*skpseenreat,�ri,l..kf:ng6malaky sen►hoayhkalioriy tmtivniclh regular mail deliveries are not made.See the accompanying notice of cancellation form for as explanation of buyer's rights. Buyer(s)received the consumer education materials provided by the Rhode Island CqL tractors Registration Board. (BVe,btitialt) Renewal by Andersen of Southern New England Buy Buyer(s 2 By: Sign>>ature of tl --nn alter ignature-�CC� / Signature, k ',# i' Ufa R 9 iA 1 S (/eQ-�-Y ` m. Print Name of Product alter Print Nam,: 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. :1c- - - - - - - - - - - - - - -9�c- - - - - - - - NQMCE OF CANt IJAY1Q� �(- - - - - - NQIICE OF CANCELLATI0�1 Date of Transaction 7'Vk ' l.3 You may cancel I Date of Transaction -7 You naq cancel this transaction,without any penaky or obligation,within this transaction,without any penaky or obigatiou,within throe business days from the above date.H you caricell,ay l throe businessdrryo from the above date.If you caned,any property traded in,any payments made by you under the I property traded in,any payments made by you under the Contract or Sala,and any negotlable Instrument executed I Contract or Sale,and any negotiable inctrumernt executed by you will be returned within ten business days following I by you will be returned within ten business days following receipt by the Salter of your cancellation notice,and arty � receipt by the Seder of your canceflation notice,and any security Interest arising out of the transaction will be security interest arising out of the transaction will be eaurcebd.Kyou rind,you must make avalbible to the Seiler ■e cameled.lfyou eaekyou must make available to the Seller at your residence,in substantially as good condition as when l at your residence,in substantially as good condition sus when received,any goods delivered to you under this Contract or I received,any goods delivered to you under this Contract or Sales,or you may,If you wish,comply with the instructions of I Sale;or you may,If you wish,comply with the instructions of the Seller regarding the return shipment of the goods at the the Seller regarding the retina shipment of the goods at the Seller's expense and risk.If you do make the goods available Seler's expense and risk.If you do snake the goods available to the Seller and the Seller does not pick them up within to the Seller and the Seller does not pick than up within twenty days of the date of cancel n,you may retain or I twenty days of the date of cancellation,you at retain or dispose of the goods without any further obligation.If you I dispose of the goods without any further obligation.N you fall to make the goods availbble to the Sefleti or If you agree I fail to make the goods available to the Seller,or Hyou agree to return the goods to the Seller and fail to do so,then to return the goods to the Seller and fall to do se,then you remain cable for performance of all obigatbns under you remalln cable for performaance of all obligations under the Contract.To cancel this transaction, moil or deliver I the Contract.To cancel this transaction, mail or delver a signed and dated copy of this cancellation notice or ay I a signed and dated copy of this cancellation notice or any other wWAm notice,or send a telegam to Renewal by I other written notice,or send a telegram to Renewal by Andersen of Southern New England at 1137 Park East Dr., i Andersen of Southern New England at 1137 Park East Dr., W�o nsocket,R102895,NOT LATER THAN MIDNIGHT OF I Woonsocke RI 0289S.NOT LATERTHAN MIDNIGHT OF 7 2:S' •12 (Date) I Z ZS•f (pate) 1 HEREBY CANCEL THIS TRANSACTION. I 1 HEREBY CANCELTHIS71"SACTiON. X BuyRir ahDrature faint NnrrR Dees Buses s Mrrt Neras DOOR RbA Copy:White Buyer Copy:Yellow Buyer Copy.Pink 4 . WV1 j t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map I Parcel Application ` Health Division Date Issued I0 l:3 Conservation Division Application Fee Planning Dept. Permit Fee 1 Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/Hyannis G�a�i3 Project Street Address V,illageOf Owner Address Telephone " O� Permit Request 6" " Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new ' Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type C=1 o . � w Lot Size Grandfathered: ❑Yes ❑ No If yes, attar pporti^ g dac'-umentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) '4 �" Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kings �i hway 4`' Yew❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other ' ' Basement Finished Area(sq.ft.) Basement Unfinished Area ( q.ft) �= Number of Baths: Full: existing new Half: existing n,ew 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: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Q Commercial ❑Yes ❑ No If yes, site plan review# q - -Current Use - Proposed Use r7 APPLICANT INFORMATION ' (BUILDER OR HOMEOWNER) Name � ,✓' / � Telephone Number Address License # /G?� �i�i%/ff Home Improvement Contractor# 1 Worker's Compensation # � WIL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO CX�SIGNATURE DATE —6 a. V e 1� • FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED - MAP/PARCEL NO. i ADDRESS VILLAGE zyf Y OWNER DATE OF INSPECTION: r �e, - ;ks v..—FOUNDATION,.,;.: ,,f FRAME — r t INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING r DATE CLOSED OUT ► , ASSOCIATION`PLAN NO.` Tr .r i . The Commonwealth of Massachusetts Department of Industrial Accidents 'Office of Investigations ip 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (BusutesslOrganization/Individual): Address: / City/State/Zip: Pho e#: 0op- Are you an employer?Check the appropriate b Type of project(required): L❑ I am a employer with 4r I am a general Lctor 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' 1 coin insurance.$ 9. ❑Building addition 'o workers' comp. insurance P• uired.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 1am a homeowner doing all work officers have exercised their I Q]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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 WIA for insurance coverage verification. I do hereby u der the pains d pen . of rjury that the information provided above is true and correci Si 'afore: C� " Date: r1 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,.an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." I An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged 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 dwelling house having not more than three apartments and who resides 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." MGL chapter 152, §25C(6)also,states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"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 out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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 city or town that the application for the permit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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. 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 under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your.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 Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.mass.gov/dia To: <deannavanr(c),gmai1.com> Subject: tent Hi Deanna, Attached are the fire certificates for the tent and proof of our liability insurance for the tent permit. Best, Kate Taylor Rental Party Plus 432 N. Falmouth Hwy. N. Falmouth, MA 02556 508-563-1960 www.trcapecod.com , Qr � 9] SS Sdd t g ze 3 fs Sl ° 7 gH 44 5 r }�. �r II z` # ya E ` a ,! a 5 J c n, r r Y7� 1 a S I 2 r CERTIFICATE OF LIABILITY INSURANCE --2/2i13 Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF Association Benefits Insurance Agency INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE 299 Ballardvale SI,Suite 1 CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT . Wilmington,MA 01887 AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC N Insured INSURER A: MA Retail Merchants WC Group Inc. Redway Rentals LLC INSURER B: d1Wa Taylor Rental Center PO Box 2017 INSURER North NO Falmouth.MA 02556 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABODE FOR THE POLICY PERIOD INDICATED,N07WTHSTANOING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT MATH RESPECT TO NHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEDHEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REOUCEO BY PAID CLAIMS. PDLICY AIDL EFFECr.YE DATE POLICY SMRAIION TYPE OF INSURNICE POLICY WMRER DATE I OMIT. GENERAL LUMUTY EACH OCCURRENCE S IpIPft GEN A®UiY FIRE DAMAGE(My—!we) S CI.UML9 MADE O OCCUR NED EXP(AA,—Fw 0 $ PERSONAL ANTY INJuaY 5 GENERAL AGGREGATE S GEM AGGREGATE MIT APPLIES PER: PRODICTS-COAIPIDPAGG S PJEaa PoPOLICYGr LOO AVTOMOMULIABILrtV CoMPJrFD 5NGlE UNR S ANYAUTO IEA P.*.4 ALL—AUTCS 9OOILv INJURY $ 3CIEDLLED AUTOS RIM:Pe<+Pe1 NREOAUT S WDLY INJURY IANGLMM1D AUTOS Imo• ri $ PROPERTY DAMAGE $ ail—j*'01 GARAGEUABIUTY AUTOONLY-EA11100ENT $ ANY AUTO OTHER TNAN EAACC $ AUTOONLY AGG S EXCESS LIABILITY FAOR OCCuaRENCE S OCCAIR ❑CWMSIAADE AGGREGATE $ S OEOUCTIXE S a mON P S RK6L4 MPENSenoN ND EMPLOYERS awl X wCSUATNT•S ORTK NIY PROPRIEI SUPARTUSU JEoLmVE EL.EADI ALOOENf A OFRCEIAMEMBER E LUDEDT S 1,000.000 u—easaae"R NO 014005030197113 V01113 1101114 EI.D:FASE-EA EINPL01'EE EQAL PROYISOIS EWIY $EP 1.000,000 EL.DSEASE-rOUGYUMIT $ 1'000,0DO OTHER OESOGPTION OF OPC ATIONSI LUGTIOIW VE1PClEY FXGLL151011n ADOEO or ENOORWuZNT I SPEOAL RRONSIONS CERTIFICATE HOLDER ADOnONALfnsvRED.INSURER LETT4L' CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIONDATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 35 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO TIE LEFT.BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE L Town of Barnstable Regulatory Services BAMNSUB f MAMThomas F.Geiler,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 f HOMEOWNER LICENSE EXEMPTION i� Please t ro law DATE: JOB LACATION: i manber ��Sue= villaag"ee "HOMEOWNER": , � f j6(, LI "gam name home phone# work phone# CURRENT MAILING ADDRESS: - - f� cityhown state zip code The current exemption for"homeowners"was extended to include owner-occuuied 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. DEFINTI'ION 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. Xperson who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be resROnsible 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 and ed"homeowner"c4itifies that he/she understands the Town of Barnstable Building Department minimum inspection pr es d requirements at she will comply with said procedures and requirements. of Homeowner Approval 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 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,particularly 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. C:\Users\demUilWppDataUzcaIMcrosoft\Wmdows\Temporary Internet Files\ContentOutlooMQRE6ZUBNIEXPRESS.doc Revised 053012 Town of Barnstable Geographic Information System June 5,2013 010024 #E0 010023 #66- 024012 #101 010022 r #52 GOB 024046 "'#57 024050 #72 024006 #1635 024045 #41 024049 #56 024054 J� 1000 010025 #40 024063 0 29 Feet #49 wk— DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:024 Parcel:050 a boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected P Owner:VALENTE,DENNIS B Total Assessed Value:$299300 arcel 1' accuracyt00'may not meal established map accuracystandards. The parcel lines on this map w +`� E are only graphic representations of Assessors tax parcels. They are not true property Co-Owner: Acreage:0.51 acres Abutters boundaries and do not represent accurate relationships to physical features on the map i. such as building locations. Location:72 BOB-WHITE RUN Buffer / !; �i}"x'�"rd�' s:ewii J(�'r.f''�i. ?'r ,vi....r -'i•ib!'hK...yra, k:.+f'�c'`'r:k':'.;y4�'1'ir,�i..` ".r�i Town of Barnstable Regulatory Services — 1 RARNSTARLE:p• V MASS. ` Building.Divisiori p�FO Wp�a. 200 Main Street, 14yannis, Mk 02601 Office: 508-862-4038 Fax: 508-790-6230 Inspection Correction Notice i I i Type of Inspection � — I Location Permit Number Owner Builder One notice to remain on job site, one notice on file in Building Department. j The following items need correcting: G i U Pal E d_D N 6:4 a_Y! Z r S C to It ? 3 �/eG 1C_ �1JSAQGTT O 10 ' I I i U . Please call: .508-862-4�8 for re-inspection. Inspected by Per, /L e% 4 ,,x� Date r , TOWN OF_BARNSTABLE BUILDING PERMIT APPLICATION . .J e' f ,�I /1 Map + Parcel Application#27� Health Division Date Issued Conservation Division Application Fee Tax Collector 1 Permit Fee Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Z. bob Oe_ Run Villages Owner Address 6- h-6` Telephone Jam' C 6cy1' �• v�0 �� Permit R_eques Square feet: 1 st floor:existing propo a V' 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project�aluat i 6 h Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single F Two Family ❑ Multi-Family(#units) Age of Exis2inished Zf Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement ll ❑Crawl ❑Walkout ❑Other Basementa(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new y 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: 17 Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Z. Commercial ❑Yes ❑No _ If yes, site plan review# .we , Current Use Proposed Use ! B DER INFORMATION �S Tel�e hon N m'-JCS p, e u ber Address'°' License# O/C/lf� Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION,DEBRIS RESULTING FROM THIS PROJECT WILLBE,TAKEN Slr G A URE ^~ rDATE�,--� ,�..�K . .° FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED .! MAP/PARCEL NO. + t ADDRESS VILLAGE OWNER Illl ,;1 DATE OF INSPECTION: FOUNDATION Pro 44, (I 3noC6,11 f FRAME 13 1-A- ( 30 ® INSULATION �- Y,. FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL x GAS: ROUGH FINAL FINAL BUILDING per. _ 9y `= DATE CLOSED OUT , i ASSOCIATION PLAN NO. �s Town of Barnstable _ Regulatory Services KAM Thomas F.Geiler,Director '°TEp �►`e Building Division Thomas Perry, CBO,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnsta b le.ma.us Office: 508-862-403 8 Fax: 508-790-6230 PLAN REVIEW �j�/° z oo'o G z 73 J�I-E� �e �a '/ Owner. � Map/Parcel: 7 0-5O Project Address 72-408 Q464 r>—A-AL/ Builder: !"7OMCP ©wN61P- 'mil ��Eioa� The following items were noted on reviewing: •PD/UD TGf,C��S .[57' �� SEA . �� rr —t� Ilk -- ,mob Pew 00ll1 C2.P--7-Z� �S a) . Reviewed by: Date: Q:Forms:Plnrvw E The Commonwealth of Massachusetts Department of Industrial Accidents Of.fice of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia ' Workers -Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers UT A licant Information Please Print Le 'bl Na731e`e(Business/Organizatio dividual): �/r/VA&r V�d 00, 964/State/Zip: ( /✓p 0�� � Phone.#� �n a appropriate :Type of project(required):. Are you an employer?Check the a ro riate bog: 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction . employees(full and/or part-time). • have hired the sub-contractors listed on the-attached sheet. 7. ❑Remodeling 2.❑ I am a'sole proprietor or partner- These sub-contractors have ship and have no employees 8. ❑Demolition employees and have workers' 'working for me in any capacity. t. 9. El Building addition [No workers' comp,insurance comp. insurance. 10. •Electrical repairs or additions ��.]_ 5. ❑ We are a corporation and its ❑ � --+� officers have exercised their l l.❑Plumbing repairs or additions '3. I am i'homeowner doing:all work . Tz �— — right 6f exemption per MGL myse .:[No workers:comp., 12,0 Roof repairs insurance:requued]t- c. 152, §1(4),and we have no 13.❑Other employees. [No workers' 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 subrnit a new affidavit indicating'such. =Contractors that check this box mutt attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees. If the sub-contractors have employees,they must provide their worker;'comp.policy number. I arc an employer that is providing workers'compensation insurance for my employees. Below is.thepolicy and job site' information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: 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 tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK,ORDBR and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of' Investigations of the bIA for insurance coverage verification. I'do hereby certify and r he pains-and p allies erju that the information provided above is true and correct �Si ttu ------ -Date; Phone#: FT use only. Do not write in this area, to be completed by city or town officiaL own: ' .Permit/License# Is Authority(circle one): d of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector r t Person: Phone#: •- Town of Barnstable Regulatory Services B^ MASS, Thomas F.Geiler,Director 1639. Building Division Tom Perry,.Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 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 ofWork: _ O �f'� - `"E§timateT:Cos C::--Address of Work: 7,91 04� Cv-t/ � Owner's Name: 7� Date-of A p cation P'V / I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law El Under$1,000 ❑B ding not owner-occupied - O pulling own permit`" _ Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED R PENALTIES OF PERJURY I hereby apply for a permit as the agent of a wner: Date Contractor N e Registration No. 2 Date O Nain Qlotmslomeaffidav �pF SHE TOy'r Town of Barnstable �P Regulatory Services BARNSTABLE, : Thomas F.Geiler,Director y MASS. �A i639• `e� Building Division TFD MA't 0 Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print ATE: a 01 r O 07 JOB LOCATION: �X� bier street village /} "HOMEOWNER'�ir �i�`y Q��D' Q OCJ�do name 46 �s homeeppphh'one# work phone# URRENT MAILING ADDRESS�,� 0,, AXI city/town 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 su ep rvisor. 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 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 unde t ed"homeo r"certifies that he/she understands the Town of Barnstable Building Department minim spection pro es qui ents and that he/she will comply with said procedures and re e e ts. Signa re of omeo • r Approval 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 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,particularly 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:forms:homeexempt C� LOT 14 � � 0 190 - LOT r 23 93 o � 1 �•' ��_____= 56t LOT � DECK SHE ti30 LOT22 o �3 0,0 RES. ZONE.- "RF" This MORTGAGE INSPECTION Plan is For FLOOD ZONE.- "C" Bank Use Only TOWN: _COTUIT __ _ REGISTRY OWNER: PAUL _R._& SALWA_M. AMORT________ DEED REF: _2093�217 --______--BUYER: DATE: _512194________________ PLAN REF: 19981 ________—SCALE:1"= 30= FT. I HEREBY CERTIFY TO B FIRST RESID IVM --CORE--- YANKEE SURVEY ___THAT THE BUILDING ZH Of ,y SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS CONSULTANTS SHOWN AND THAT ITS POSITION DOES _ _ CONFORM PAIL 40B (SUITE 1) i TO THE ZONING LAW SETBACK REQUIREMENTS OF THE A.ME9ITHEW y INDUSTRY ROAD TOWN OF _ _BARNSTABLE-------------AND THAT No. 32088 Q IT DOES_ NOT_ LIE WITHIN THE SPECIAL FLOOD HAZARD o MARSTONS MILLS, MA. 02648 AREA AS SHOWN ON THE H.U.D. MAP DATED_V4/,92__ Fs £�`STzgE� a`` TEL: 428—0055 L-11 mm nit —Panel 250001 0021 D s ��t « os` FAX 420-5553 __ _ ________ THIS PLAN NOT MADE FROM A UMENT 14762 DPG AUL A ERITHEW PLS SURVEY NOT TO BE USED FOR FENCES ETC. Sheds USA Inc. - Home Depot specs Delivered - Built - Guaranteed Rool'Construction Approx Roof Height Walls 7/16"OSB sheathing 6tt wide peak-8'* 2x4 construction,24"on center 2x4 trusses w/TPI plates,24"on center 8ft wide peak-8'4"* Siding Types: aft,3-tab,self-sealing asphalt shingles 8ft wide gambrel -9'* Pre-primed Shed panel All Peak roof pitches are 5/12 10ft wide peak-8'11" Pine(1x6 horizontal tongue&groove) Gambrel roof pitch is 12/12 at bottom IOft Nvide gambrel -97' Cedar(1x6 horizontal tongue&groove) changing to 5/12 pitch at the top 12ft wide peak-9'8" Vinyl Siding on 1/2"plywood Gable vents are optional in 2006 12ft wide gambrel - 10'3" Peal:/Gambrel std wall height-71-1/2" Optional architectural shingles *add 2"if 2x6joists Extended Peak front wall only height-75" On Peak roofs only Add 15"for 7ft walls Optional 7ft walls are 86-1/2"tall _l ..x l + -f.- Jam. PT 4x4 CENTER BEAM ON 12ft GABLE MOTH ONLY (NOT ON 8' & 10' MOE) I_ j `f Windoivs Doors Fluor Size: 18"wide x 22" tall (approx) Standard 40"double door (except 6'x6'shed) 5/8"OSB Includes flower box&shutters Optional 27",54",& 66"doors optional 5/8"PT plywood Optional window screens Optional 66"or 96"roll-up door* PT Floor joists- 16"on center Wooden Sheds-functional windows Door height 68",opening height 66-1/2" 2x4*- 6'& 8'wide sheds Vinyl Sheds-non-functional windows opening width 1/2"less than door (*optional upgrade to 2x6 With optional upgrade to functional Door opening height on 7ft walls 80" @ 12"on center) *96"roll-up door only available on 12'gambrels 2x6*- 10'& 12'wide sheds (*optional upgrade to 12"o.c.) Concrete block supports PT 4x4 runner under center of 12'gable width sheds only Note:Options may not be available for all shcds.Call yourDish'ibutor or Sheds USA for more information. \:�'l'achnical\Sheds\Shut-Cutaway-Diagram-Flll.doc Version: 11/12/06