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0370 CLAMSHELL COVE ROAD
i „ .�....:.. ., ...., ..... ... :...... .... ...�,..-+,n.�!r,.-, - aft--. ,`.-_.»... !'T: -rr-^rb-s.-.. .;x"'r.�T,-�a...r+R.^r-f--•."�r.'?�+f�a�: :-,..�=l-,m-•...+„p•.�. _ -- - l - 41c � � ,1 q. � @�8 I ....._.... ......w•rnEN--------' --'— E6 J E� FLOOR PLANGARAGE 0 �60�! i'1646 z I k\ t a e o LrtJ U-1 6 6 t Ll- FRONT ELEVATION SIDE ELEVATION REAR ELEVATION C1) L wZZZ :. CD Lo G ROOF FRAMING PLAN HH i C-3 ES U.1 al w�rwacwan w NEW LLI IL LU erwwva�rrm".rv.on s.. f O ® J Gj -� ,.,.. .. im:a MR mN-T. rn;; NRCNEN L�! Q COURTYARD �cc C O _ � plpROOM WINO I •••:•:. 1 m aeMOD. .,.«.,. 9UNF T .� TNR.WALI CONDi. r.._ - «4«... ..4.. ..4.. It RREMOD. erocL:..4! euos,' e� ...... n :......:.._:...i.... F- w.i.c. C3-I ( -- ''•A!WAROOM eNTRANGf Nul 1 i SECTION 0 ROOF SUNROOM ---!. �j T �-�—o F -no ^••�-: i. yys; 1 -,• i o r MASTER 0 EAPANCED I' LMNO ROOM '^ Q COVEREDTERRACE it Z ' J (� i W _.J ,�..-.sue..... __________________ 4- J _..a..,..«.... �.. .. NOTES: .'« Q d w cO W co: .....e.-.................� elgprOpN owArR.�rrrwwwOdWrer a L o NEN WOODEN DECK liJ O rl�rKRRrrotlr�ARWE R.VIRRr W cowrrucrexromNNrNrorrOw N.al.o.rrrre V MASTER tt YMTEa 'rteK awmoeaa.n,Eoror..RmaK..mu CE4Y4SZk i ei,reNEnaonrcwNRmr .)WomlOr nrraaorwlal4iwOmrrE1N{WYRfLYLr, W W 0 oew®rarvwromenERrArmrnrrim Nwo Z O. c7 rr W.r,urE.rrsmr•.ruaeurR iiW Nrcmmast.nwuonawr.orm ' mLLovWwwcruarwvrwromrR+.or.uARuro. - - - WALE". W W�'tlaonornvRRRnswaamaNlwro• FIRST FLOOR PLAN Ilrrt•O' lUt�EMENT "I pArR n.w"" in' ar.uwRn�Kw M.m �waadKna ' _ W . I rRgE.Mrro mr laYdM✓R r)IrrAr mfAlrq.roou drecra WOWS VRLRN W rYnnOrteO M rnrR.OfFA1Rr pI•.RR SECTION QMASTER BEDROOMMATM r,Y�arMrClrr„w.Rrra rwRAw p•IROWC LEGEND: OHQ.NO.: C=I a� A md„;e r.'.'rwmew• wa,o CONSMUGTiONTO WREMOVED Al Nrr{Crp,KRu�aNura NEW COMRTRUCigN w R.weo naa rR er•Ar n caerruc.w m lid - ------------ ------ --- =-- ----- I- ------ I i_ ----_. -__.-___=- 1 6g1 tj ' j 1 , I 1 � • tj ______J I , i �I i i urirY aoow \./i»» i• Ik� A - . ------------- '--------- - -- - -----', O - -- {� I ; ll I I 1 ; I I I , I 1 I. I i I r � I I , 1 I I I I i I I " Q F- O BASEMENT FLOOR PLAN ' pV � O U - W:LL J o a•_ O W N. CL - . . W 0.Ir•W o Z. W.n • : Z d.co' WTE:. . •' ]onenois. . Dim No.: . � •' A2 �Tile Town of Barnstable _ Building Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept M'S• Posted Until Final Inspection Has Been Made. 163P Permit mod' Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit No. B-16-486 Applicant Name: JOHN J. DELANEY Map/Lot: 001_001 Date Issued: 03/16/2016 Current Use: Zoning District: RF Permit Type: Siding/Windows/Roof/Doors Expiration Date: 09/16/2016 Contractor Name: JOHN J. DELANEY Location: 370 CLAMSHELL COVE ROAD,COTUIT w _ , _ Est. Project Cost: $ 110,000.00 Contractor License: 125529 Owner on Record: PENELOPE P FEUILLAN TRUST Permit Fee: $561.00 Address: PO BOX 55851 Fee Paid: \$561.00 BOSTON, MA 02205-5851 Date: 3/16/2016 Description: Replacement Windows(12) U-Value.29 Replacement Doors(6). .� Project Review Req � r Building Official f This permit shall be deemed abandoned and invalid unless the work authorized by this.permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-lawsand codes. This permit shall be displayed in a location clearly visible from access street or road a`nd shall be maintained open for public inspection for the entire duration of the work until the completion of the same. The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: t 1.Foundation or Footing ; f 2.Sheathing Inspection . 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed i 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection S.Prior to Covering Structural Members(Frame Inspection) 6.Insulation 7.Final Inspection before Occupancy Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (asset forth in MGL c.142A). Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Town of Barnstable *Permit Expires 6 moi hs fi issue date �l Regulatory Services Fee snatveraB�, �bA Richard V.Scali,Director 3II I L �Jti Building Division Fr„ATL S 6'j T' 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 PERNUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 66 I " 00( ) � ../_ Property Address 3� /� -slag/ l (�U /�U L,(jL�,�I • Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Co BAVK6f fim-lc?1' 1 Contractor's Name /1 Iy �I J�/ � 'f Telephone Number .5',09 2-0 (o Home Improvement Contractor License#(if applicable)_-/2 c� q Email: /Nra Construction Supervisor's License#(if applicable). - (}Q q q 61 XWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor XWPI?Fss ❑ I am the Homeowner 1m) I have Worker's Compensation Insurance / I MAR 0 2 2016 Insurance Company Name D��l /� � �, S� GQ f°N /1 Workman's Comp.Policy# F Sq�NSTAB(.E Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side p� Replacement Windows/doors/sliders.U-Value m 0� I (maximum.32)#of windows Z— #of doors: to ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is r uir SIGNATURE: L� C:\Users\Decollik\Ap D \Local\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\2PIOlDHR\EXPRESS.doc Revised 040215 The Commonwealth of Massachusehts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111, w#snv.mass goi�,1dia Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(BusinessfOtsmizationudividual): J\J al jq A�L TO L Address: l U Rd M , Ciry/StatelZip: S l Phone# 6j 69'1(M'(6*-�S_ Are you an employer?Check the appropriate box: general contractor and I Type of project(required): 1.X I am a employer with yJ 4._ ❑ I am a g employees(fall and/or pad-time). s 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_ 0 Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'.comp.insurance comp.insuranee.I required.] 5. ❑ We are a corporation and its ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L E]Plumbing repairs or additions myself[No workers',comp. right of exemption per MGL 12.❑Roof repairs insurance required.]i c. 152,§1(4),and we have no employees.[No workers' 13.�ZOther U1 VdD 9, comp.insurance required.] *Any applicant that checks boa#1 mast also fill out the section below showing their workers'compensation policy information. ?Homeowners who submit this affidavu indicating they are doing all work and then hue outside contractors mast submit a new affidavit indicating such ZCoatractoas 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 enWloj.vm Below is the policy and job site information Insurance Company Name:_,Z I X6944 Policy#or.Self-ins.Lic.* W CS'"� � — 3'O ,V 6 d f� Expiration Date: ✓a �,A� i S$J��,,// Job Site Address:c)7rDL 1� Al . L,lu,t City/State/zip: MA o Z 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerlifyUnderthepfflns Mand penalties of peduty that the information provided above is hue and correct Si lure: Date: ~Z J' o?D/ Phone#: Official use only. Do not write in this area,to be completed by city or town officiaL City.or Town: . ' Permit/Ucense# Issuing Authority(circle one): L Board of-Health 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: E .�r,►sz$ "AM L Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division Thomas.Perry,CBO Building Commissioner 200 Main Street. Hyannis,MA 02601 www.town.barnstable.ma:us Office: 508-862-4038. Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder tw 771"S ii-- ,as prof the subject property hereby authorize a-i l^J E. to act on my.behalf, in all matters relative to work authorized by this building permit application for: �7`7U Ct-4q H t'S F4 G:�l_-(_.-.(a;�t✓i--. .r `— T-c 4 t T' (Address.of Job) 4 ! ol S' a r nerJ Dat \J�nt. IhCa; iL S u fi Print Name If Property Owner is applyi reverse side. ng for permit,pleas_a complete the Homeowners License Exemption Form on the re C:\Users\L)ecollik\AppDatalLocal\MierosofhWihdows\Temporary IntemetFilcs\Content.0utlook\2P101DMEXPRtiSS.doc Revised.w;15 ,Ac V CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 11/16/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER DOWLING &O'NEIL INSURANCE AGENCY INC NAME: 973 IYANNOUGH RD PHONE FAX PO BOX 1990 Arc No): HYANNIS, MA 02601 A DRIESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A: LM Insurance Corporation 33600 INSURED INSURER B: J J DELANEY INC 20 RASCALLY RABBIT ROAD UNIT 2 INSURERC: MARSTON MILLS MA 02648 INSURERD: INSURER E: INSURER F: COVERAGES CERT!F!CA.TE NUMBER: 27325240 -- REv!S1_0N 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 ADDL SUBR POLICY EFF POLICY EXP ' LTR TYPE OF INSURANCE POLICY NUMBER __.(MMIDDIYYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR C' PREMISES Ee acarnence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OVSVNED A�OESULED AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Peracciden $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I RETENTIONS $ A WORKERS COMPENSATION WC5-31S-318101-015 11/2/2015 11/2/2016 PER OTH- AND EMPLOYERS,LIABILITY YIN N STATURE 1. IER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1000000 OFFICER/MEMBER EXCLUDED? aN N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1000000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1000000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached It more space Is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 200 MAIN STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. HYANNIS MA 02601 i AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 27325240 1 1-318101 1 15-16'WC 1 yogeah.patilelibertymutual.com 1 11/16/2015 10:59:41 PM (PST) I Page 1 of 1 I Massachusetts-Department of public Safety Board of Building Regulations and Standards Construction Supervisor i License: CS409961 JOEIN J DELANE}� 271 PLUM ST Weit Barnstable 141A �1IiA Expiration Commissioner 04/14/2016 t i gTie:o!�Consnmer.Affair-s.&Business•Regulation OME IMPRO.. MENT CONTRACTOR R IstrafJo�. e9 1 9, Type: �A tratio Individual. _. . JOMN J DELANEY' q JOHN DELANEY 271.PLUM'ST W.BARNSTABLE,MA 026 Undersecretary i _ Town of Barnstable Builds g Post This Card So That it is Visible From the Street Approved Plans Must be Retained on Job and this Card Must be Kept � .f DAMMA�g , MAS& }Posted Until Final Inspection Has Been Made. Permit ice• lwhere a Certificate of Occupancy is Required,such Building shall Not be Occupied until'a final Inspection has been made. J Permit i Permit No. B-17-428 Applicant Name: 10HN J. DELANEY Approvals Date Issued: 03/02/2017 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 09/02/2017 Foundation: Residential Map/Lot: 001-001 Zoning District: RF Sheathing: Location: 370 CLAMSHELL COVE ROAD,COTUIT Contractor Name: JOHN J DELANEY Framing: 1 Owner on Record: PENELOPE P FEUILLAN TRUST Contractor License:',CS-009961 2 Address: 100 FEDERAL ST -- Est. Project Cost: $60,000.00 Chimney: 4 BOSTON, MA 02110 Permit Fee: $712.00 Description: vault ceilings in 3 bedrooms,remodel 2 baths&1 1/2 bath add 5 Insulation: upgrade smokes co Fee Paid: $712.00 skylights pg Final: � Date: , 3/2/2017 Project Review Req: vault ceilings in 3 bedrooms,remodel 2 baths&1 1/2 bath add 5 skylights upgrade smokes co Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas- This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work:l 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT % ? ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION14 Map Parcel �y Application # O Health Division \� ���� Date Issu . IN Conservation Division 1-7 Applicati n Planning Dept. \�\(� Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address 3 o cLmc4 tit Village Owner able B ,e au 'lla) �� Address - Telephone 1 Permit Request L_4 G 1 L 1 kU j-jj a G + 1 L,6 Add \l .5ttq iq/I ig + 43 T Square feet: 1 st floor: existing3gproposed 2nd floor: existing proposed Total new lJ Zoning District Flood Plain 1 Groundwater Overlay Project Valuation QM Construction Type M� O Lot Size 2- I�S Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure WL&S Historic House: ❑Yes _&-No On Old King's Highway: ❑Yes ,�I`No Basement Type: Aru II ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) 229 7 Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: existing 0 new Total Room Count (not including baths): existing ne First Floor Room Count Heat Type and Fuel: Gas ❑Oil ❑ Electric ❑ Other Central Air: ItYes ❑ No Fireplaces: Existing J New Existing wood/coal stove: ❑Yes atfNo Detached garagexisting ❑ 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 ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �� Telephone Number "fog,- wo - �aJrsC�) Address 5W &aLm67- License# c-5- qW C� 7- <e�ff�f �� ► �Z8 Home Improvement Contractor# �ZSSa� 1 JVPI 6tkt ZLT 4',Q Worker's Compensation # ALL CONSTRUCT ON DEBRIS RESULTING FROM THIS PROJECT WIL BE TAKEN TO SIGNATURE DATE 2 `I7 -D 1 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL N0. - ADDRESS VILLAGE:. .. F a OWNER DATE OF INSPECTION: -; FOUNDATION FRAME INSULATION-\L1� FIREPLACE ELECTRICAL: ROUGH FINAL ' PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING , 'DATE CLOSED OUT r ASSOCIATION PLAN NO. f `t The Commonwealth of Massachusetts Department of Indtcstrial Accidents 1. Office of Investigations 600 Washington Street t� C Boston, MA 02111 _ yy/ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Ise ibl 3. Name (Business/organization/Individual): Z, Address: D 2 City./State/Zip: lJ Phone #:Are you an employer? Check the appropriate box: Type of project(required): 1. r with _ 4, ❑ I am a general contractor and 1 6• ❑ New construction' am a employe employees(full and/or part-time). * have hired the sub-contractors listed on the attached sheet. 7. Remodeling 2.❑ 1 am a sole proprietor or partner ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.$. 10.❑ Electrical repairs or addi[i required.] 5. We are a corporation and its 3.❑ 1 am a homeowner doing all work officers have exercised their l I.[}Plumbing repairs or.additi 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. tContractors 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,' 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy"and job site information. / ,J Insurance Company Name: Policy#or Self-ins, Lie.#: �� �5 i1 ® p Expiration Date: Job Site Address: City/State/Zip Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration datf Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 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. 1 do hereby c rd Ender t e airs and penalties of perjury that the information provided above is true and correct. Si nat re: Date: Z " 7'� Phone.#: Sds q , ' 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 S. Plumbing Inspector 6. Other Phone#: Contact Person: -Information and lnstructxons 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 Linder 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 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-contractor(s)name(s), address(es) and phone number(s) along with their certificates) 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 maybe 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 pen-nit 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 applicani 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 burn 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: i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 61.7.-727-4900 ext 406 or'1-877-MASSAFE Fax # 61.7-727-7749 Revised 4-24-07 wwvr.mass.gov/dia EN•E•RO�C CONSERVATION APPLICATION FORM FOR ENERG�C EFFICICIENCY FOR ON-E; AND TWO-FA ML Y DET kCHED RESXDENTrAL CONSTRUCTION (780 C1YIR 61.00) Applicant Nam6: Site Address: print TOWN: Applicant Phone: Applicant Signature: Date of Application: NE•W CONSTRUCTION: choose ONE of the-following two'o tl.ons 780 CMR.TABLE 6107.1 PRESCRIPTIVE ENVELOPE COMPONENT CRITER A FOR NEW ONE- AND TWO-FAMILY BUILDINGS M-A) t M]NRAUM Ceiling or Slab QOption 1: Basement Fenestration exposed Wall Floor Wall Perimeter A-FUE HSPF U-factor floors R-Value PI-Value R-Value R Va1uc R:Value and Depth National Appliancc•En R-10) ConscryAdin Act(NA .35 R-3 8 R-19 R 19 R-10 4 ft . 1997 am'rndod,mini cater as npiplicabIr Note: This form is not rcquir6d ifyou choose either of the two Versions of REScheck as listed below. ❑ Option 2: RES check Version 4.1.2 or later variant soft arc.analysis must be m copleted 780 CMR 6107.3.2 �. REScheck—Web which can.be accessed at http•//www CnCrgycodes aoy/resch(-,cltj bzx ores ORAz.VRA-TIO s.TQ maSTil�G)' IN o zi s E s OLD* *)3uildings under 5 years old must use option#1 or#2 in New Construction section above. Complete the following formula to determine the %% of glazing: (a) Gross Wall & Ceiling Area equals Formula: (100 x b a) ' SF 100 x - _ % of glazing a (b).Glazing area equals SF b If •lazin T <-40%.use the chart belpw. • . If lazing is> 40 %% rgcced to "SUi4ROOM" section 780 CMR TABLE 6101.3 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING. LOW-RISE RESIDENTIAL BUILDINGS M� A4IN7MUM ❑ ..Ceiling and Slab Peri Fenestration gxposcd floors Wall Floor Basement Wall -Val U-factor R-Va)uc R-Value R-value R-Value and De.39 R-37 a R-13 . R-19R-10 4�R EL R-30 ceiling insulation may be iiscd in place of R-37 if the insulation achieves the full R-value over the entire ceiling area i.e. not compressed over exterior Walls, and includingan access o enin s . ' SUNROOM—An addition or alteration to an existing building/dwelling unit where the to' glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of 1 addition. Note: Owner to fill out Consurner In orrnation,Farm found in Appendix 120.P A FYC Guide to Flood Corrst7,tictiou in Hi;h 6Yiud Ar•erts: J10 nrpl► {'Yiird Zoi1-c Ngassaclllisetts Cheddist 611, Comp1zance (780 CnIfR 5301:2.f.1) (� CI Compli; 1.1 'SCOPE ....... 110 mph _ Wind Speed (3-sec. gust) ......... ......................................... .......... Wind Exposure.Category ................................................:.:....... ........................................ .....•...... ... .. — Wind Exposure Category................Engineering Required For Entire Project ..............................•. . — 1.2 APPLICABILITY Number of Stories (a roof which exceeds 8 in 12 slope shall be considered a story) stories 5 2 stories _ Roof Pitch (Fig 2) 5 12:12 _ . .................................................................... Mean Roof Height ................:......................:......................(Fig 2)............................................... —ft 5 80' — BuildingWidth,W ............................................................: (FIg 3)...................:..................._........— — .........(Fig 3)........................•. 580, — Building Length, L ..................................................... <3:1 (Fig.4 • Building Aspect Ratio (L/W) ...............................................( 9 )................................ .. ......... ... 5 6'8" Nominal Height of Tallest OpeningZ ...........:................. .....(Fig 4 ....................... 1-.3 FRAMING CONNECTIONS General compliance with framing connections..,.................(Table 2)............................................................... _ 2.1 FOUNDATION Foundation Walls meeting requirements of 780 CMR 5404.1 ' Concrete............................................................I....................,..... .................................... _ Concrete Masonry........... 2.2 ANCHORAGE TO FOUNDATION1.3, 518"Anchor Bolts,imbedded or 5/8"Proprietary Mechanical Anchors as an alternative in concrete only m Bolt Spacing—general ......................:.....:...........:.(Table 4).................:............................. — Bolt Spacing from endCoint of plate 1.............(Fig 5)..................:.................. in. S 6'— 12", — Bolt Embedment—concrete...................:.....................(Fig 5).....................................:..........._in.>_7" - Bolt Embedment—masonry..............................:...........(Fig 5).....:......I............................ In. i 15" — PlateWasher..:.............................................................(Fig 5)....................................... ......>3'x3' x%" 3.1 FLOORS .•...(Per 780 CMR Cha ter 55 ..................Floor-framing member members spans checked (P P """"""'• 9 P ��� Maximum Floor Opening Dimension """"""".............................•.....(Fig 6)....:.......,... ft<_ 2 Full Height Wall Studs at Floor Openings less than 2' from Exterior Wall (Fig 6)....................................... — Maximum Floor Joist Setbacks Supporting Loadbearing Walls. or Shearwall................(Fig 7)....................................................T ft _ — Maximum Cantilevered Floor-joists _< Supporting Loadbearing Walls or Shearwa11 ................(Fig 8).................,...................:................_ — Floor.Bracing at Endwalls.............................................. ...... 9)............................................................... .. — Floor Sheathing Type (per 780 CMR Chapter 55).....:............••••""..... in. ....................................................... (per 780 CMR Chapter 55)........................ — Floor Sheathing Thickness .......................:............•••• (Table 2).. _d nails at in edge/_in field Floor Sheathing Fasteriing..............................................:...( — 4.1 WALLS Wall Height ft 51Y Loadbearing walls..........:............................................(Fig 10 and Table 5)...•.......................—ft 5 20' y Non-Loadbearing walls ......:.....'........ ...............(Fig 10 and Table 5)..........................._ — Wall Stud Spacing (Fig10-and Table 5 — Wall Story Offsets ..:...(Figs 7 &8)......:..................................... ft s d. — 4.2 EXTERIOR WALLS' Wood Studs 5) in. Loadbearingwall$....................................................... (Table ............................�2x_ — — •-,�— .............2x ft in. Non-Loadbearing walls ................................................(Table 5)...........•:.. — — . _ — Gable End Wall Bracing' Full Helght Endwall Studs............................:...............(Fig 10)...................................................... .......... ... .... .................•..(Fig 11 ft zW/3 WSP•Attic Floor Length................... ( 9 ............................................ . Gypsum Ceiling Length (if WSP not used).... ............:. FI 11 ............................._ft?0.9W : and 2 x 4 Continuous Lateral Brace @ 6 ft. o;.c. ..(Fig,11 • nr t Y R rr.ilino furrino strips D 16' spacing,Tin,with 2 x 4 blocking @ 4 ft. spacing in end joist or truss bays AFYC Ccrirle to 1-floodcorrstr11c6011 ill.Hi, /r 1/I�i�rd ffreus: !10 nrplr IYirr� Lo�rr' I�/[assacIi>tse><ts C1eciclisf f'or Com.phance (70 ci\ u301.2.1.1)' Loadbearing Wall Connections ' Lateral (no.of 16d common nails).......................'.........(Tables 7)....................................................... Non-Loadbearing Wall Connections Lateral (no. of 16d common nails)................................(Table 8)....................................................... Load Bearing Wall Openings (record largest opening but check all openings for compliance to Table 9) Header Spans ...........(Table 9)..................I................_ft_in. :5 1.1' . Sill Plate Spans ............(Table 9)................................ _ — ............................ Full Height Studs (no. of studs)........:...........................(Table 9). ......................:............................... Non-Load Bearing Wall Openings (record largest opening but check all openings for compliance to Table 9) Header Spans...... (Table 9)................................. —ft_in. <_ 12' .................................. Table 9 .................................. ft_in. 5 12" Sill Plate Spans.... .........;.......... •( ) Full Height Studs (no. of studs)...............................:....(Table 9)...............................................:. .... Exterior Wall Sheathing to Resist Uplift and Shear Simultaneously4 Minimum Building Dimension, W Nominal Height of.Tallest OpeningZ .. s 618" SheathingType..............................................(note 4).......................... ......................,.... Edge Nail.Spacing................:........................(Table 10 or note 4 if less)............:.........: in. g............... Table 10 .................................... ...... in. Field Nail Spacing .-....•••••.•;�•••••••••• .......•( ) Shear Connection (no. of 16d common nails)(Table 10)......................................................._ P Full-Height Sheathing 10 .............:..................................... Percent Full-Het 9 g.............. (Table ) 5%Additional Sheathing for Wall with Opening > 6'8'(Design Concepts)................. .. Maximum Building Dimension, L Nominal Height of Tallest Openingz....... .................................................................... SheathingType..............................................(note 4)....................................................... Edge Nail Spacing (Table 11 or note 4 if less)........................ in. Field Nail Spacing ......................................:..(Table 11)................ ................................ in. .... Shear Connection(no. of 16d common nails)(Table 11).......................,............................... Percent Full-Height Sheathin (Table 11).............................................:......._% 5%Additional Sheathing for Wall.with'Opening > 6'8'(Design Concepts)................ ... Wall Cladding Raftedfor Wind Speed?...........................:....................,............. ..:........,................................................... 5.1 ROOFS. Roof framing member spans checked?...................:....(For Rafters use AWC Span Tool, see B BRS Website). Roof Overhang ...................................................(Figure 19) ........... ft s smaller of 2'or U3 Truss or Rafter Connections at Loadbearing Walls Proprietary Connectors plf Uplift................................................(Table 12)............................................ - plf Lateral .... (Table 12)...............................................L= Shear...............................................(Table 12 ........I............... .....S= •plf Ridge Strap Connections, if collar ties not used per page 21... (fable 13)...............................T- p If Gable Rake Outlooker.......I.........:........................(Figure 20) ............. ft s smaller of 2' or U2 . Truss or Rafter Connections at Non'Loadbearing Walls Proprietary Connectors Uplift ...(Table 14)......................... - . Lateral (no. of 16d common nails)...(Table 14).................I......I...............L= lb, (per Roof Sheathing Type................:..................................(p 780 CMR Chapters ters 58 Roof Sheathing Thickness ........................................and 59) .............. .._ in. z 7/16'WSP Roof Sheathing Fastening .....................(Table 2).........:.......................... .................— Notes: 1. This checklist shall be met in its entirety, excluding the specific exception noted in 2, to comply with the requirements of 780 CMR•5301.2.1.1 Item 1. If the checklist is met in its entirety then the following metal straps and hold downs are.not required per the WFCM 110 mph Guide: a. Steel Straps per Figure 5 b. 2b Gage Straps per Figure 11 c. Uplift Straps per Figure 14 d. All Straps per Figure 17 e. Comer Stud Hold Downs per Figure 18a and Figure 18b 2.. ' Exception:Opening heights of up to 8 ft.shall be permitted when 5% is added to the percent full-height sheathing requirements shown in Tables 10 and 11. 3. The bottom sill plate in exterior walls shall be a minimum 2 in. nominal thickness pressure treated#2-grade. AI-VC Gicide to l- e)ort Constrrrclion h, JJi('Jr Hlil7d'-11'eas: 110 rnph 1.1'icrrf Zoil.e massacluisetts Checklist for •Com1)IJaz1ce (7R0 C IZ 5301.2J.:I)' 4. a. -From Tables 10 and 11 and location of wall sheathing and Building Aspect Ratio, determine Percent Full-HI Sheathing and Nail Spacing requirements b. Wood Structural Panels shall be minimum thickness of 7/16" and be installed as follows: I." Panels shall be installed with strength axis parallel to studs. it. All horizontal joWs'shall occur over and be nailed to framing. ill. On single story construction, panels shall be attached to bottom.plates and top member of the dou lop plate. iv. On two story construction, upper panels shall be attached to the top member of the upper double t( plate and to band joist at bottom of panel. Upper attachment of lower panel shall be made to band and lower attachment made to lowest plate at first floor framing. v. Horizontal nail spacing at double top plates, band joists, and girders shall be a double row of 8d f staggered M 3 inches on center per figures below: Vertical and Horizontal Nailing for,Panel Attach) 5. Glazing protection: a)new house or horizontal addition—required if project is 1 mile or closer to shore (generally, sot: Rte, 28 or north of Rte. 6) b)vertical addition—not required unless there is'extensive renovation to the first floor c)replacement windows—needs energy conservatlon compliance only(chap 93) 6.Wood Frame Construction Manual (WFCM)for 11.0 MPH, Exposure B may be obtained from the American Wood Count (AWC)website. •-WHEN THIS EDGE RESTS DN FPAMING USE W MAILS. II II 1 1 l l I I I - I • IJ - ' • 11 1 w Y l 11 It , 1 11 rl i , Q z N t , ,I f1 I Lt IY 11 r o I I z4 11 ,1 I 1 r l II 'd fI aim i i W io it �: . .11 fl II 11. E II Irk FRAMING MEMBERS EDGE II u KIrF�tSdEDIA'rE _J it 11 1 I i I II W ii 11 ., 3A I it 1 2 , 1 W I 1 II It ll I H1,14f r r--L- - -----y - - 1 STAGc.EREo Dt?U NAIL PATTERN PANEL PANkt_ PANL A EDGE � G DOUBLE"L EDGE SPACM DETAL See Detail on Next Page Detail Vertical and Horizonlal Nailing Vertical and Horizontal Nailing for Panel Attachment fo.r Panel Attachment KAM .�� To wof.Barnstable Regulatory. Services Richard V.Scali,:Director: Building:Division. . . . 'Thomas Perry,CBO . . Building Commissioner 200 Main Street,:Hyannis,:MA 02601 wymtown.ba rnsta b le.m a.us Office: .508-862-4038 Fax:. 508-790-6230 :Property Owner Must Complete and SignThis Section If Using A Builder: All a.1. ,.as( arof the subject-property hereby authorize to action my behalf,. in all matters:relative to work authorized by this:building permit application f6r: ! : J L`. �L.i4•"cC�✓cr•� t �—cv ru T (Address of Job) . Vigna r ner. :Dat . . . Print Name If Property Owner is:applying for permit,please complete the_Homeowners License Ezemptiou Form on the. reverse side . . C:\UsersUkcollik\AppDnt&Local\Microsoft\Windows\Temporaiylntemet FileslConteni.ouil6ok\2PIOIDHR\EXP.RGSS.doe . Revised,040215 0 a §� - 3 , I � } . \ \\ z ^~~ c k ,- _ a izz BUILDING DEPT FEB 17 2017 TOWN OF BAHNSTABLE 2/17/2017 IMG 5530.JPG ki 3 — 7 _ a c� t ` f a r , https://mail-googl e.com/m ai I/LdO/?tatr-w mg nbox/15a4c l69cce53adO?projector=l 1/1 BUILDING DEFT FEB 17 2017 FOWN of BARNSTABU 2/17/2017 IMG 5529.JPG i I https://mail.google.com/m ai I/u/0/?tatr-w mffi nbox/15a4c i 69cce53adO?projector=l 1/1 O W C O pmp �_ m z z o m D � co r- rr ,n y M U'7 I I I O) 3 0 U _ppN7 _ O m t� ry N a L 31SViSNUV8-J0 NMO.t UOZ L T 833 ld3G ONloiim 2/17/2017 IMG 5528.JPG i ^ h• r DOOR STAYS r - j . httpsJ/mail.google.com/mail/W0/?tab=W m#k nbOx/15a4cl69cce53ad0?projector=l 1/1 J � CD LLJ D N z Z �{ m U_ Qca _ W 5 u- z CC) O 2/17/2017 IMG 5527.JPG pp I r https://m ai l.googl e.com/m ai I/u/O✓?tab=w m#q nbox/15a4c l69cce53adO?projector=l �/� 31JILDING DEPT FEB 17 2017 i OWN OF BARNSTABLE 2/17/2017 IMG 5537.JPG I h i =i I Mtps://mail.google.com/mail/tdOr tad=wm*nbox/15a4cl69cce53adO?Ixojector=1 1/1 3�9`d1SNyd8�o NMpl t�OZ t S31 ld�a'�Nia��n9 i1 Yi- a I N �I N s• � I E 3 c� a .ti U ti c p E a � w J Cn � N z Co W O u- z 0 i %TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map- Parcel 0 //vG Application # Health Division l *4 �F ' 3I31 (� Conservation Division ! OwNOF �?016 ate Issued... Application Fee Planning Dept. e��NSTq Permit FeeI Ll V ' Date Definitive Plan Approved by Planning Board e�F Historic - OKH Preservation/ Hyannis Evr A'zL 5F4J - Project Street Address _5 1 Chgm5 8 L L C®1_ AcL Village Owner �k�Jk Ltffif- VS1A,1 It Rt1 'MUST AddressQW&Y505 T60,MA 022oSS�St Telephone Cn - q1q - q 8 o(Q� " maW L , !Aw K i Amia Permit Request iR �. I� b )e f-b�� Q-AQ_A4iW1r1AT I�d Awd ffCC9Q�-1� E Lk -IL S ����-� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain /V 0 Groundwater Overlay Project Valuation Construction Type _���f�'Yh� Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family k' Two Family ❑ Multi-Family(# units) Age of Existing Structure ,Historic House: ❑Yes 1�I o On Old King's Highway: ❑Yes ANo Basement Type: XFull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) ,r Basement Unfinished Area (sq.ft) N, Number of Baths: Full: existing_ new Half: existing ii new y Number of Bedrooms: existing new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: J WGas ❑Oil ❑ Electric ❑ Other Central Air: XYes ❑ No Fireplaces: Existing New n— Existing wood/coal stove: ❑Yes )1il'No Detached garage-N'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 ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name v A ✓ Telephone Number \09' _t p 'U,�r6 Addressor) Z,- License# 6 S - 60 qq 61 IS Home Improvement Contractor# Email - ,' i AA, C1914A Worker's Compensation # ItitS 31S--319/01-61.S ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 1�nuh&60_5 IQA66�� SIGNATURE DATE r FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED s MAP/ PARCEL NO. e ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION t FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL a FINAL BUILDING t DATE.CLOSED OUT ASSOCIATION PLAN NO. Tlie Commonwealth of-Vassaclrusetts ��cartrra<eiTt ofridzcrtriafAcciderrtr n : _ rA 0,ffrce of1m.-wtrgadom 600 Washington J' eet Boston,3A 02M ivivinniasmgmMia Warkers' Campensat an.Insurance Affidavit:Bmldei-s(Contracturs/EIect ricians/Ph mbers Applicant Inf n-oration Please Print Le��iIy Nam ,t�i,:� � 1� Address: ( 1 A Q rA a Z Ciigfstatel � 'bane 4 st) " - Are 3rou an employer?Check the appropriate box: Type of project(requited}: 1. I am a employer with 4 ❑I am a general contractor and I employees(full andfor part time * have Hired.the suFr-contractors 6_ EINew construction, 2.❑ I am a sole proprietor orpartner- listed on the attached sheet T_ ❑Remodeling slip and have no employees. These sab-c=tractors have g_ ❑Demolition wo dug-, forme in any capacity employees andhave workers' 9. Building addition [No w0doers'comp.insurance comp.insurattm, l? regnired] 5. We are a corpomfion and its 10,❑Electrical repairs oar additions � officers have exercised their 3.❑ I am.a fiomeflwuer doing all wont 11.❑Plumbingrepairs or additions myself-[No workers'comp- Ti f tt of eKempfion per MGL 12- Roofrepairs insurance rehired j i C.152,§1(4k andwe have no employees.[No workers' .- Other comp-insurance required-1 #Any apprm ffiatchedcsbox#1 also fillcraithesectioaberawshmsiagtheirvmAereco®pensationpolicyinfomsdon_ I liameoamerswho submft this affidavif in%Ucatiag they are•dafng RUwal aad then hie oatsidednntractorsmmst mtmit a newsffidavit in&cv�nv s„rh ICaatUCtoestbzt dhedrThis b=must attached aaadditional sheet shormTng the naa-eof the sub-ccutcsctaa snd state whether or not those entideshwe exgloyees I€thesub-cantactomblveemplows,theynnssipmuidetheir nmrkers'comp.poHUmmbu. I am an emplojier that is prai idiag workers'eongw.isah'ort inmiranca-for my entployaees. ,Selo;v is tlta policy lmd job site it formatibm Insurance Com.panyName: Llz M(&Af q i h W6, Policy or Self--ins_Lic. � 1 1 1®1 - V 1,C- RkpifationDate: I-Q ` �(pl 1, Job ERR.1§ddtes � �1 'k� �� ' City/StatetTg: M& 6U 3- Attach a copy of the workers'compensationpolicy decIlaration page(showing the policy number and expiration date). Failme to secure coverage as requireduader Section 25A o€MGL m M can lead to the imposition of r*im;m 1 penalties of a fine up to$1,500 00 and'ar one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDERand a free of up to$250-00 a day against the violator. Se addsed that a cagy of this statement maybe forwarded to the Office of lavesEigations ofthe DFA for insurance coverage wrifficatim I do lieraby c 0 rdsr tha pants aitdgeualfies afperjrar}'thatSte in ornzaiiort proiuled above s--llsb uz and correct Sitmatu Dates �� cam/, Phone ik �D� 2 0- Of fdid use anly. Do clot evrite in tfzb urea,to be campleted by city ortonm o,f frcrat City or Tomm; Pernut/License 4 I Issuing Anthorify(cacIe one): . L Board of Health 2.wilding Department 3.C ityl Town Clerk 4.Electrical Inspector 5.Ph€mbmg Inspector 6.Other Contact Person: Phone#: r ormation and Iast-ucti S Mkssar-hasetfs General Laws chapter 152 regrmes all employers`to provide workers'compensation far their employees. purm.a„ this stiff,an emp&yee is defined as.`�.every person in the.service of another under any contract:of hn e, express or implied,oral or writf m An ez rcym^is defined as-an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a Joint emerprise,and mcludmg the legal representatives of a deceased employer,or the rrceivur of trustee of au individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling horse having not more than three apartments and who resides therein,or the occupant of tare - dWeII$ghouse of anotherwho employs persons to do maintmance,construction or repair work on such dwelling house thereto shall notbecanse of such employment be deemed to be an employer. or on the grounds or building app�nanf MGL chapter 152,§25C(t7 also sties that"every state or localTicPn.�gagencyshallwigfiord 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 notproduced acceptable evidence of c6mpliance,with the i„cnrance-coverage required." Additionally,MGL chaptr x 152,§25C(7)states"Neither the commonwealth nor any of its poIiiical subdivisions shall enter into any contract for the p erformance ofpublic wo33c umtil acceptable evidence of compliance with the in surer ce._ regret ements of this chapter have been presented to the contracting aodhoiity-7 1 Apphcan-ts Please till oirt the worker'compensation affidavit completely,by checking ine boxes that apply to yourr situation and,if necessary,supply sob-contractors)name(s), address(es)and phone number(s) along with their certificate(s)o imstaance. Li nitedLiabr7ity Companies(LLC)or Limited Liabi7ity`Pa Immmhips(LLP)withno employees other than the members or pazt e:M are not requi ed to carry workers'compensation msurmce. If an LLC or LLP does have employees,apolicyisregnired. Be advised that this affdEvit maybe submitted to the DeparfinentofIudusfrial Accidents for confirmation of insor nce coverage. Also be sure to sign and date the affidavit The affidavit should be retimmed to the city or town that the application for the peanit or license is b eing requested,not the Department of h&-j a 'A ccinie �honldyon have any gneslions regardmg the law or ifyou are req�ed to obfiam a workers' r their compensation policy,please call the Department at the number listed below. self-in�companies should ente self-insordnce license nummbes on the appropriate line. City or Town Officials Please b e suure that the affidavit is complete and priatEd Iegiibly. 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 store to fill in the pemLit/license number which will be used as a reference�be.r. In addition,an applicant zt must:submit multiple penis dlicense applications in any given year,need.only submit one affidavit indicating cent m policy inforr ation(;if necessary)and under"Job site Address"the applicant should wnt�"all locations in (�t3'or town)."A copy of the-affidavit that has been officially s ur ped or marked by the city.or town maybe provided to the - applicant as proof that a valid affidavit is on file for fa are permits or.licenses_ Anew affidavitim st be filed oil each year.Where a home owner or citizen is obtaining a license or per itnotielatedto any business or commercial vtutu e (ie.a dog license or pemut to burn leaves said person is NOT regtmcd to complete this affidavit The Office of Tnvesligaduns would hike to th 2rnlc you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Departmenfs address,telephone and fax number: y Tire CaMMQrLWcaIft of .chnsett�-- Deparbnent of Iadustcial Accidents ==of Itvewotio-= ��4�ashingtan S`tre�t I, Borg MA 0�111 Tc,-1.4 617'27-49QO Cxt 406 or 1—M MA-S AFR Fax#617 727 7749 Revised 4-24-07 gagid AWC Guide to Woad Consfr-adiorr in fKi;--Ir WZrrd Areas:IZ0 rrrptr kYrrrd ZorL Massachusetts Checklist for COMPOaace (7sa aiR5301. (.1)t - CAI cs,cic . . - compliance 1.1 SCOPE. Wind Spegd p-ser~gust)----—_------_-_._ -_-_-- _-- -.1 i D mph Wind Exposure CaiegDry__.._—_.- -- -__—.-- —_ __. B Wind Exposure Category-_-..........._Engineering Requ'red ForFsrtire Projeft---------------------------------------C 12 APPLICABILITY ' -Number Df Stories(a roof which exceeds B in 12 slope shah be considered a story) stDries 52 sinries . Roof Pifr -_. --_-- ---__.- _(Fig 2) __-_ _<1212 Mean Roof Height _ _.----.__-- _—(Fg _ft -<-33• Building Width,W_ _.____-__— .(Fig 3).— _—_...--__— ft <_B(y Building Length,L _.__ _—_—__-- _ (Fg 3) -_---___ -- =ft s 8V Building Aspect Ratio(LAIV) ___-- —(Fig 4}-- ---- 5 3_1 Nominal Height of Tallest Dpening2 _ -------(Fig 4)-- ___—__ 5 6'B' 1.3 FRAMlN6 CDNKECTIQNS General compl-rancawith framing mnnecZDns-._—_�—.(Tablet)__ 2.1 FOUNDATIDN - FDUndafiDn Walls meeting requkements of TBD CMR 5404.1 Conan--------------------------•----------------------- -- ........---•--------------••----------------------•---------- Conctete Masonry--------------------------— --------- --- 22- ANCHORAGETD FDUNDATlDNII 3 51B'Anchor Bolts imbedded or 5/8"Proprietary Merhania Anchors as an altemafive in concrete only Bolt Spgcuig-general--••--•------..._-•--=-------- (Table 4) __.r..:_-- in. Bolt Spacuig from endIlDmt of plate -----(Fig 5) - in._<6`-12'. Bolt Embedment-concrete—_. (Fig 5).--. _-_—_— in.>7' Bolt Embedment-masonry-—,-----(Fig 5) '--_-..-- in._>15" Ply vvasher__.- _.— ----(Fg 3'x 3'x%• 3_t FLODRS FloDi-frarning mernberspans checked -------(per 7BO CMR Chapfar55)------___--- Maximum RDorOj>ming Dimension Full I-feaght Wag Studs at Floor Openings less f-ian 2'from Exterior Wall(Fig 6)--------------------------------------- MtXIT1 Floor Joist Setbacks SuppDifng Loadbearing Waifs or Shearwall---(Fig 7) ------- -.—fit 5 d Maximum Cantilevered Floor Joists , SuppDrfing Lbadbearing Wags Dr Shea U---- "(Fig B) ft _<,.d -FloorBracing at EndwaIIs—._�_.. -- Floor Sheathing Type .`_---_-_____ —(per7B0 CMR-Chapter S5) — Floor Sheathing Thldmess ___ '—(per 730 CMR Chapter 55)__.. .- in_ Floor Sheathing Fasi�rimg__._._.____---_---; (Table 2)_=d nails at in edge/_in field 4_f WALLS ' Wall Height Lnadbearing wags., _—_ - _ (Fig If)and Table 5)_-_- _ _it 51 D' Nan-LDadbea ing walls--. (Fg 10 and Table 5)_—__.--_ft's 2lr Wall Stud Spring _.__—.._ --—.-._.(Fg 10 and Table 5)_--_—_in.s 24'n c Wag Story Dffsets _ _-_ - _—(Fgs 7&B)— __--. —ft s d ' 42 EXT JOldWALLS' Wood Studs - Laadbeariag•walls—____.___ Non4-Dadbearing walls.__.__---------_--.-:(Table S)__. —irL- Gable End Wall Bracing t I Full HeiOt Endwall Studs-._--- _.(Fg 10) — WSP-Affic F)DDr Length Gypsum CeMng Length(if WSP not used)_ --(Fig 11) ------,_-_—ft z 0_9W and 2 x4 Continuous Lahaal Bract Q 6 ft D.C.-(Fig 11)__._._................__... or 1 x 3 ceTmg furring ships @ 16'spacing-min with 2 x 4 biorddng @ 4 ft_spacing in end joist or truss bays Doable Tap Plafs Splice Length — _-__ (Fig 13.and Table 6).__ __T -- —ft _ Spline GDnnection(no.of 16d common naffs)— (fable 6). --- A FYC Guide fo TVoad Carrsfruc6an in High [Ykd Area: 110 Faph Krnd Zone Affassaclinseffs Check for Co>' Iialzce(7so C�-1R-5301_ZI.1)1 Loadbearing Wall Connections ' Lateral(no.of 16d common nails)_._ - (Tables 7)_ - —•---- Non--11 adbearing Wag Cormac funs Loral(no_of 16d common nails) _.—(Table B) Load Bearing Wall openings(record largest opening but check all openings for connprance to Table 9) Header Spans .-_-- - — ___.—_(Table 9)_�_ _._ _ft—in._<1 V 5fD Plate Spans ___-- -- -- (Table 9)—_ --__—••-_It—in.<I V FLA Height Studs (no_ of surds)___ --(Table — NOn4-cad,Bearing Wall Openings(record largest opening blrt check all openings for compliance to Table 9) Headef Spans.-,------____—___—_.__—.-(Table 9)--__ _— _ft_in_<1Z Sill Plate Spans.___ __;�. ___ (Table 9)-- --_ft—in_512' Full Height Studs(no_of surds) _(Table 9)_-- __— Dderior Wall Sheathing to Resist Uplift and Sheaf SimulfaneousV Mfnfmurn Building Dimension,W Nominal Height of Tallest Openingz .................. —._—_.—_-__ --_.._.— 5 BIB* Sheathing Type- _—_—_—__(note ------ Edge Nail Spacing-- —(fable 10 or note 4 if less)—_—---_ in- Feld Nail Sparing—_.__--_--�---•(Table 10)_----- — in Shear Connection (no_of 16d common nails)(Table 10).-.__ Percent Full-Hefght.Sheathfng.__---_-(Table 10)_--_--_ -_-•------ —°� 5%Additional Sheathing for Will with ripening>.6'8(Design Concepts)___.____—. Mmdmum Br.ulding Dimension,L - Nominal Height of Tallest OpeningZ—__—_ Sheathing Type----------_--(note 4) -- -------- Edge Nail Sparing—_ —(fable 11 or ncls 4 if less) Feld Nail Spacing (fable 11)_ —_____—--•--• ---- in- Shear Connection(no. of 16d common nails)(Table 11)__._._� Percent FulMeight Sheathing— (fable 11) —-_-- -- Wail Cladding _ Rated for Wind Speed?—_-- _ —_—.__—.— - ------------ m ROOFS Roof framing member spans checked?_--- _(For Rafters use AWC Span Too[,see.BBRS Websib_-) Roof Overhang -----------------------------(Figure 19)---_-- ft s smaller of 2'or L/3 Truss or Rafter Connections at Loadbearing Walls = Proprfet iry Connectors . . Ups ---- ---(Table 12)--- --- ---U= plf —_(Table 12)-- ---L= plf Shear—_ _—[Table 12)_—. .Ridge Strap Connections,if collar ties not used per page 21_ (Table 13)__—__—__--T= pIf Gable Rake (Figure,20 ft s smaller of Z or LJ2 ' Truss or Rafter Connec5ons at Non-l-aadbearing Walls Proprietary Connectors Uplift—_—:_--�.--- (Table 14) _—l1= lb. Lateral(no.of i 6d common nails)--(Table 14)..._.__.__.—_----------------- - lb_ Roof Sheaifiing Type—__—_ -- (per 73D CMR Chapters 5B and 59).__._.------ - Robf-Sheathing Thickness---- — _-- _ _in_?7116'WSP Roof Sheathing Fastening—___— _--• (Table 2) Notes: 1. . This checklist shall be met in its entirety,excluding the spec5c excep5on noted in 2,to comply vrifh the requirements of 73D GMR53D1.2.1.1 Item 1. If the checklist is met in Its entirety then the following metal straps and hold downs are not required per the WFCM 110 mph Guide: a_ StEel Straps per Figure b. 2b Gage Straps per Figure 11 r_ Uprdt Straps per Figure 14 d_ All Straps per Figure 17 e_ Comer Stud Hold Downs per Figure ISa and Figure 18b 2. 'E=eptiort Dpmhg heights ofup,to B ft.shall be permitted whe'§ addeA' percent full4'reight sheathing _ requhwffarrts shdwn in Tables 1 D and 11. 3- The bottom sill plate in extEdDr walls shaA be a minanunr 2 fn_nomM thickness pressure treated#2-grade. r` -ATVC Gctide to iYood Corrrtr'ucdorr irr Hjri h H?i dAreas_ ILO rnptr oaxe Massachusetts Checklist for Compliance(7so cuRs3.oi- 4. _ a. From Tables 10 and 11 and locAon of wall shi!afhing and Building Aspect Ratio,determine Peroertt Full-Height Sheathing and NA Spacing requirements . b. Wood Structural Panels shall be minimum thickness of 7116"and be installed as fonows: i. Panels shall be installed Wh strength an's parallel to studs. ; I All horizontal join1S shall occur over and bei nailed to framing. ur_ On single stoiy CDnstruC6on,panels shall be attached b bottom plates and top inember of the double top platy nr. On two story construction,upper panels shall be attached to the top member of the upper double top plate and to band joist at bottom of panel Upper attachment of lower paned shall be made to band joist and lower attachment made to lowest plate at first fioorframing. V. Hor®ntal nab spacing at double top pkdes, band joists,and girders shall-be a double row of ad staggered at 3 inches on center per figures below:Vertical and Horizontal NarTing for Panel Attachment 5. Glazing protection:a)'new house orhor®ntal addition—required If pplert'is 1 mile or closer to shore(generally,south of Rta%ZB or north of Rfe-6) b)vertical addition—not required uriless there is extensive renovation in the first floor c)replacernentwuidows—needs energy conservation mmpliarice only(chap 93) 6.Wood Frame Construction Manual(WFCM).for 110 MPH, Exposure B maybe obtained from the Americn Wood Council (AWC)web Site c{gr �GEFtESrS DR RiA1,rlAX�tsEsd WAiL� • u 11 . • cr 11 1 - • tl 11 t J tl t tl tl !Ei Q o [ J ri H i' M t `rl • - tt ft t 'Q 71 t r t7 [�s 1 ► Q. I '�. It (1 • I l Ja 1 rK 1 f [ •ht it II E, t I I kf fa It [ F II LI tt7 ri II 1 i• , t E It ;I t 11 t 2 t [ 1 1 S II fl 1 t •� It It t l t [ [ 1_x trl _ -- -- - - ' CDt17�.t=� - � STRG� 3`ldYi NAE:�kGtJG PAS �`� uAxpArnH r PrZI�ID:z •L 0Qi KEU'AJL®GESPACNC oE3AL ' See Dafat�[fln Text Page t Detail Vertical and HDrizontal Ralung , VeriiMl AM HoAmntal Nailing for Panel Attachment fbr Panel Atmlirnent ' HARNSTAHM "� �,� Town of Barnstable Regulatory.Services Richard V.Scali,Director. 'Building Division Thomas Perry,COO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstablema.us Office: 508-862-4038" Fax:*508-790-6230. Property Owner.Must Complete and Sign This. Section If Using A.Builder tZ boa _ t� ,.as rofthe subject property hereby authorize .1 • is�.n,.J E n l to act on my:behalf,. in all matters relative to work authorized by this building pemrit application for: (Address.of Job). . . ��l�'K �r i9�'J���.�raj /Jr�, ,/tiar%E:t~ • Dat J L• a� r ner Print Name If Property Owner is applying for permit,.please complete the Homeowners License Exemption Form on the reverse side. C:\Users\Decollik\AppDataUAKalwicrosoft\Windows\Temporary Internet.Files\Content.outlook\2PIOlDHK.\HXPRESS.doc Revised o40215 I Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS4)09961 JOHN J DELANE} - '•,. r• 271 PLUM ST West Barnstable AA Expiration Commissioner 04114=16 Office of,Consnmer Affairs.&'Business Regntation j OMEtMPROY ENT CONTRACTOR Regwstration 1 5529 Type. -. Firatio l Individua t - P, i 1 JOHN'J'DELANEY JOHN DELANEY i 271 PLUM ST D, W.BARNSTABLE,MA 02\ Undersecretary 4 S ACORV CERTIFICATE OF LIABILITY INSURANCE DATE(MAAIDD,WYY) 11/16/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER DOWLING &O'NEIL INSURANCE AGENCY INC NAME:cT 973 IYANNOUGH RD PHONE FAX PO BOX 1990 E-MAIL ac No): HYANNIS, MA 02601 ADDRESS: INSURERS AFFORDING COVERAGE NAIC 0 INSURER A: LM Insurance Corporation 33600 INSURED INSURER B: J J DELANEY INC 20 RASCALLY RABBIT ROAD UNIT 2 INSURERC: MARSTON MILLS MA 02648 INSURERD: INSURER E: INSURER F: COVERAGES CERT!F!CAdTE NUMBER: 2,1325240 - REV!SIOM 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 ADDL SUER POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DDIYYYY MMIDDIYYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ -UA—MA RE GE CLAIMS-MADE EJ OCCUR PREMISES Ea occune.,. $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (CEO accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Pea 'dent UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION WC5-31S-318101-015 11/2/2015 11/2/2016 �/ STATUTE ERH AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT $ 1000000 OFFICERIMEMBER EXCLUDED? ❑N NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1000000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1000000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. HYANNIS MA 02601 AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 27325240 1 1-31e101 1 15-16 WC I yogesh.patil®libertymutual.com 1 11/16/2015 10:59:41 PM (PST) I Page 1 of 1 Q W > to o•� t��. W �� f� ,o SAYE eia cox OVER 2X40 RAFTERS ow ac. WITH SPRAY FOAM PISULATIc" 12 NEW VaLux g SKYLIGHT TEW ASPHALT SHPIGLE ROOF OVERHANG 41, ggNSrgeC F 37.0 CLAMSHELL COVE RD J`�J.J.DCLANCI:INC. COTUff, MA R ¢on rouw:r.�wnunm a� ISSUED FOR PERMIT-15 MARCH 2O16 v �� •u Mu�wRemc SCALE: 1/4" = 11-011 TOWER ROOF FRAMING Q W A 17 EAVE �a ccx OVER 2zmo RAFTERS 04& acv WITH CLOSED CtLL SPRAY FOAM 14SULATION 12 mW veLux g SKYLIGHT NEW ASPHALT SHPIGLE ROOF OVERHANG r 'V y Taw Mq�l� Ar NoFe ?�16 ' ggNs�q e� soijing&Remode/iq�, 370 CLAMSHELL COVE RD JJ.DELA�INC. COTUIT, MA ISSUED FOR PERMIT-15 MARCH 2O16 pnwrly ems SCALE: 1/4" = V-011 TOWER ROOF FRAMING -17 Q—KAI, IeA Town of Barnstable *Permit#R_ Regulatory Services Fee 6months from issue date BARNSPABLE MASS. �, Richard V.Scali,Directorair:a 039. �0 0}�� Building Division '�'� Paul Roma,Building Commissioner 172017 200 Main Street,Hyannis,IvIA16F2601 www.town.bamstable.ma.us � Office: 508-862-4038 z� �b Fkx: 508-790-6230 EXPRESS PERNIIT APPLICATION - RESIDENTIAL ONLY Not Vaud without Red X-Press Imprint Map/parcel Number 00 CD I �J Property Address 37 b CIAM614 l(r � /(L'. ( �� )'Residential Value of Work$ /01 000 Minimum fee oof—$35.00 for work under$6000.00 Owner's Name&Address IT Contractor's Name :�v JI, /A U16 / Telephone Number St'` 20-Z;,g� Home Improvement Contractor License#(if applicable)125 A Email:j 1� I 1,4chLIR tr f�L,6QA Construction Supervisor's License#(if applicable) GS-- 60g9,6 1 XWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name �p t d1J(i Workman's Comp.Policy# Uj�,� Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ` K Replacement Windows/doors/sliders.U-Value 0 (maximum.32)#of windows a #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is requ7QSIGNATURE: 4.AA ,4 Zn Q:IWPFILES\FO S uilding permit forms\EXPRESS.doc 06/20/16 j The Comwomveaithh et,f Mussadrrrsettx Dapartmeut oflfndrrsbid Acdd=& Qjfue of 1MWS*afi0rs 600 Waslhineon Sfrwf Boston,MA 02111 term maragovIdia Wkwlmre CmnpensafeunInsurarrce avid BaflderslContracturs Electricians/Plumbers Apph Information Please Prof Ere�Iv c is DZbq8 one �0 �� -602' Are you an emplayer?:Check the appropriate bar; Type of project(regnnred}_ I.JXI am a 1 with 4 ❑I am a general contractor and I 6_ ❑New oonstiixtion employees(andibr part�me)-* lave luredlhe sub contract�oss 2.❑ I am a sale proprietar orpartaw- listed an the attached sheet I- ❑Remodeling. ship and have no employees Thew sub-contractors have 8_ ❑Demolition. wariung forme in any rapacity_ employees and have wmkers' 9..❑B.ui1dtng addition INo wodmrs,ccmp.ms>r:e comp- I required_] 5. ❑ We are a corporation and its 10_❑Electrical repairs or ad&Eo s 3.❑ I am a homeowner doing all work. officers have exercised their 1L❑Plumbing repairs or adcfitions of on.per mpsf3€[No woLTaers'comp- F 1?❑Roofrepaits J iummance required-]T �oyem[[No dWod=s we,have no 13,Kb?rher k ACE Cp1 U(D comp- ) *gayapglic=dmtcheaabosMmastalsoialont*eswiaabdIowshowingttekvoaeWcmmmpensaffaupa&cyinffi=2 an- #Ekmevwvers Who sot=ft dm aft i g dey axe doing zU wan$=4 dum him onside coatactarsnnst submit a new affidau indirstine such ZContiactoa fart ctechtbfs.box nmast att erly as additional sheet stoning ttename of @se sab-r .and state Whethet or not those enfitiies ha-e employees.If thesnt•canhadas have emplgyws,they=srymvidethw wm*ers'ansp.pGhcgatmber. lam an Betory is the pv cy and f ob she information, Insurance Company Name- � Si �t 'Policy or A,dSelf-insLin.# h)/,,/.��° .� C)I //D Ipit^atianI3afe: / "eZ "c�-Q 7 Job Sib. d 2 �t �")j K�uU.1/1 Aftach a.capf of the workere comapensationpolicy declaration page(showing the policy number and expiration.date). Failure to secure coverage as required under Section 25A of MCiI.c 157 can lead to the imposition of criminal penalties of a fine up to SUODOD tindlor one=yearimprisonmml,as well as civil penalties in the form of a STOP WORK URDERand a fine of up l a MOO a day against the violator_ Be adtnsed fizat a copy of this sbkment maybe forwarded to the Office of Irrvestigafions ofthe DIAL for unsure=coverage verifrcatinn. I do Ifemby under pains and pwahiFer afpedW7 that flue iraforwra&a prm-kW abm a 1s 6 ae and correct Sim Tate: Phone ik 1C / 75'D t),ffreid use an F. Do not merits in M3 area to be cmmpleted by dip artown o,oWal City or Town: Perna ;tense; Leg Auflwrity(drde one): L Board of Health 19 BuTdiag Department 3.CRyfrown Clerk 4`Electrical hmp=tor S.Ph mnbing Lupector 6.other Contact Person Phout-9: 6 Laformation and Instracfions _ MRCS chnseft General Laves chBPtEr 152 rrq=m all employ=to Provide wnrloMe=DPMSB ion far their rMpla3n=' Perin this sue,as Mayer is dtfined az¢.evezp person in i e service of anadmr under any contmzt ofhury esp¢$ss or implied,oral or within." r is.d0f aed as wan hIE ideal,paxfn�a=cfiiion;corporation or offim legal emtity,or any two or more of the foregoing engaged in a Joint etCPrise,and including the legal rep�fives of a deceased eMPIoyer,or t3ac rmcim or tmstee of an individual,pa tam ship,association or other legal entity,employing employees. However the owner of a,dwelling house having not mine than three apmimecft and who resides therein,or the occupant of the - dwelling house of another who emplays pessouus to do Maintenance,.camsjrnr'Fi on or repair wo&on such dwelling house or on the grounds or bua&mg appmt mt¢lh=to shall not because of such employmeaxt be deemed to be an employer." MGL chapter 152,§25C(6)also stirs that.¢every state or local licensing agency shall withhold the iSSttallCe or renewal of a Tic— e.or permit to operate a business or to construe buildings in the couumo :wealth for any applic anf Who has not produced acceptable evidence of compliance with the ft sarance coY�ge ram" Additionally,M'(H-chapter 152,§25C(7)starts¢Neithmthe nor;zny ofitspolifical subdivisions shall ert into any contract for the perf=auce ofpnbho work until acceptable evidence of compliance with I±Le insurance, requir 2eats of this chapter have been presented to the contracting aofhoav--" AppIicauits PIease fill out tilt wot3aas'compensation affidavit complete n by checking the boxes that apply to Your situation and,if sob contnartor(s)name(s), addresses)and phoneuumnber(s) along with.their cerfificate(s) of n�sace-ry;supply s wimno to exs other than the insurance_ Limit�edLiabuZity Companies(LLC)or LioritEdLiabilitp'Parfne�shiF (LLP). emp Y members or parfiaerS�are not rbgai ed to cony workers'compensation insozance_ If an LLC or LLP does have employees,a policy is requited. Be advised that this a$daYrt may be sabmith-,d in the Department of Industrial Accidents for confirmation of IDsur =coverage Also be sure to sign and date the affidavit. The affidavit should be retuned to the city or town that the application for the pem it or license is being requested,not the Department of jndnSf11al ACcid=:ts_ Should you have any questions reg3rdIM9 the law or ifyou are required to obtai a woiis' comp=saion po&ey,please call the Depattme;nt at the number listed below. Self-insured companies should enter their self insoz-mce license number on the line_ City or Town Officials t - Please be sure that the afdavrt is complete and printedlegtfly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event:the Office ofInvestidos has to contY_tYamrcgardingthe agplicant- Please be sure to tall in the peri it cease mtmber which will be used as a reference nirnber_ In-addition,an applicant tivat mast submit mult)Ie peimAjliceose apphtations m any given year,need only submit one affidavit indic lmg caamut policy fi fo=uaation(-if ne�cessmy)and undea`Job Sits Address"fe applicant should vine"all locations in (�Y or j town)-"A copy of the:-affidavit that has been officially stamped or mmiced by the city or town maybe provided to the applicant as prooythat a valid affidavit is on file for tiutnre permits or Iice:nsm A new afidavrtmust be filled oil each year.Where a home owner or citi=is obtaining a license or pe mit not related�D any business or commercial vent= a dog license:or peimi t to bum leaves etc.)said person is NOT requ Qtd to complete tints affidavit The Office of Tn7csfigalions would him to than k-You in advance for your coopeaaiion and should you have any quesfi=, please do not hesitato to give us a call. The Departmmf s address,telephone and fax mm�bcr_ Of MAI_Mch . - Deparfinent Gf In a]AGcid�nts �Q4 Tin t - BQ MA O�11F Tel.#617' -4.900 axt 406 car 1477 MA SSA F Fax#617'27 7749 R.evised.4-24-07 - W ¢� E. ttstasra KUR Town of Barnstable Regulatory Services: Richard V:Scali,:Director Building:Division. Thomas Perry,CBO Building Commissioner. :200 Main.Street, Hyannis,MA 02601 www.town.ba rnstable•ma.us- Office: 508-8624038 Fax: 508 790-G230 Property Owner Must Complete and Sign This Section If Ueirig A.Builder, as. r-of the subject.propertp hereby authorize. a .�.n;._1 E `f to act on my behalf; in all.matters.relative to\vork authorized by.this building peimit application for.: (Address of job) �✓�II:II�:ri.f'�.��J��'.LC.r8j:�,1.�� �ysiEz. • r ner. *Dat PM.nt Name . . . If Property Owner is applying for permit,please complete the.Homeowners License Exemption Fortis od the. reverse side. C`\Users\becollik\AppbatulLoca[\Microsoft\Windows\Tempormy lntemet Files\Content.Outlook\2PIOIDHR\ExPRr-SS.doc Rev ised 64021.5 l VA 11:(MM/DDfYYYY) ACCIAWO CERTIFICATE OF LIABILITY INSURANCE �„�-• F __o,,11/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS j 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 CONIA I Linda Sullivan HOAX NAME: DOWLING &O'NEIL INSURANCE AGENCY INC,N..EAQ: (508)775-1620 (A//C No): ADDRESS: Isullivan@doins.com .)73 IYANNOUGH RD. INSUKtK S A►FOKOING COVI:HAGIe NAIC N HYANNIS MA 02601 INSURERA: LM INS CORP 33600 INSURED INSURER B: J J DELANEY INC INSUKtKC: INSURER D: 20 RASCALLY RABBIT ROAD UNIT 2 INSURER E: MARSTON MILLS MA 02fi4tl INSUKtK 1-: COVERAGES CERTIFICATE NUMBER: 117644 REVISION NUMBER: IIIIS IS 10 CLRIIFY IIIAI I I IL POLICILS OF INSUhANCL LISILU ULLOW IIAVL ULLN ISSULU 10 1IIL INSURLU NAMLU AUOVL FOR IIIL POLICY PLRIOU INUIC:AILU. NO I WI I I IS IANUING ANY KL0UIHLMLN1, ILHM ON CONUIIION OF ANY CON IRAOI Of; 011ILH UOCUMLNI WIIII RLSPLCI 10 WI11011 11118 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. INSK TYPE OF INSURANCE DL ADISUBR POLICY NUMBER VOUCY tFF vOUCY 6Y`YI UMRS COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE $ 1 JAMA(*- 10 HFNI FII CLAIMS-MADE Floccun pw-MI:4-S(t-,l nrnlrrnnrr.) $ M-1)FXV(Any nnr.rnrznn) $ NIA PERSONAL 6 ADV INJURY $ GEN'L AGGREGATE LIMIT Arr'LIESr'ER. GENERAL AGGREGATE $ HPOI IGY U.-C I U 1 0C F'KCIUI ICI;.COMP/OP AGG $ OIHFN: $ AUIOMOtlIIJ:LIAtlIL11Y (OMrrjrIErnI,INGL t $ y ANYAIIIO BODILY INJURY(0b1•0015un) $ v ALL OWNED SCHEDULED NIA BODILY INJURY(r w d aJnnp $ AUTOS AUTOS NON-OWNED PnorERTY D G,E4 $ `� HIRED AUTOS All I C,S (I'rr nrnnrra) 0 UMBRELLA LIAB 000 1H EACH OCCURREN 6 E $ 2S txCESS UAW CLAIMS-MADE WA AGGREGATE $ a. DED RETENTION 1$ WOKKtKS COMVt OTH- NSA IION X ^Egll1 I F ►K - AND EMPLOYERS'LIABILITY ANWKO,+KI)-IC,HMAKINFWFXI-0I11w- YIN E.L.EACH ACCIDENT 1,0(W00 1110-09 I NIAI NIA NIA WC531S318101016 11/02/2016 11/02/2017 (Mmldnlury in NH) rJ.ul.^,I-A^,�•I•A�Mw OrFF $ 1,000,000 If yrs,drsrnhr.11nnrr S Uf;CHIP I ION 01-OVfI/A I IONS hrtnw E.L.DI EASE-r OLICY LIMB $ 1,000,000 N/A 01=11CKIV I ION OF OPERA I IONS I LOCA I IONS I VhHICL:S (ACOKO 101,Addltlonat Hamarks Sehadula,mry he Michad If mnra space Is raqulrad) Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts If the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.nrass.govAwd/workers-compensationlinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street AU I HOK ILtU K6VKtStN I A 1 IVt ' Hyannis MA 02601 `. l ..'•�' Y Denial M.Crl�wray,CPCU,Vile PrasirJent—Ral;idual Market—WCRIBMA (c 1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I. Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-009961 Construction Supervisor JOHN J DELANEY 271 PLUM ST cd .-'s - WEST BARNSTABLE MA�-02668 Expiration: Commissioner 04/1412018 / Lic hefo e th r registrati office o f e eBPiration n valid for i lop con so date. If Ind' B°ston )plaza 116 ite-5 ner a�0 s and Business tO ret se only r M 'Regulation r _ Not valid Without r• I 4/5/2016 IMG_2879.JPG 3 https:Hm ai I.google.com/mai I/u/0/?tab=wm#i nbox/153e8l9eaf9d240f?projector=1 1/1 4/5/2016 IMG 2878.JPG 31GVISINuit https://m ai l.googl e.com/m ai I/L/0/?tali w m#i nbox/153e8l9eaf9d240f?proj ector=l 1/1 4/5/2016 IM G_2877.JPG lip t https:Hm ai l.google.com/mai I/L/O/?tab=wmM ni)ox/153e8l9eaf9d240f?projector=1 1/1 4/5/2016 IM G_2876.J PG hUps://m ai l.google.com/m ai I/W0/?tab=wm#li nbox/153e8l9eaf9d240f?projector=l 1/1 4/5/2016 IM G_2875.JPG Jil IT https://m ai I.googl e.com/m ai I/u/0/?tab=w mA nbox/l53e8l9eaf9d240f?proj ector=1 1l1 4/5/2016 IM G_2871.J PG I . 1 T �w.neva4uz�.. 3181�15r��i � .J� IYiYIr l https://mail.google.com/mai I/u/Q/?tab=wm#i nbox/153e8l a5d6ff77al?projector=l 1/1 f N 8N I� (D O N v s vw �s 4 _ a led I Aj CN 1 r n j ro Z5 8 a' u-� r� _U C E 3 0 co E U pN O O co CD o E � \ . $ } ' \ 0 § y { / � a : \ \ L `© m, \ CO : § f � � _ NJ � - - m � � © yO�TBEt��4 TOWN OF BARNSTABLE 33ARNISTAM NAM 039. V BUILDING . INSPECTOR APPLICATION FOR PERMIT TO ... . ....... ...... . .................................................................. TYPE OF CONSTRUCTION .................. .......................................................................... 19�,2— TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a perniit according to the following information: Location ...... . .. .......... ProposedUse ............ ... ............ ......................................................................................................................... Zoning District .......7................................... ...................Fire District .............. ....................................... Nameof Owner .-A . ........ ...../.... ... . ........... ......Address ............... ...... ................................................ Nameof Builder ... ... ... ............ ....... ................................................ Nameof Architect ...... . ....... ............. ... ... . . ... ............ Address ........�. ..... . . ....... .............................. • Number of Rooms ................7....... ..... ............................................... Exterior ........ ..................................Roofing ............................ .............. Floors ..............1!!:� ..�-- ...............................................Interior ..... ............................................. Heating ......... ............ ... .....................................................Plumbing ...../10.4,,�.. ... ...................................................... Jam' �7 '5 Fireplace ............ ..................................................................Approximate Cost ...............................2 e�- ..................................... Definitive Plan Approved by Planning Board -------------—------------- lea Diagram of Lot and Building with Dimensions SUBJECT TO APPROVAL OF BOARD QF_HEALIH_____ 96 � � -� 09/7 re -.1 ul 0 -:t _j LO j ca 0 kN a- LLJ _y U-) > 0 Cy 1- 0 V) < — U),� U) d 0 >: - w 0 LQ Uj �D Uj Uj 0 ;27 CL C) LU 0 >- CL Q ULLJ X < I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ...... ......f§ ........................ K ` " Ihillzrick George ~ ' one story ^ _ � . No ..�����... Permit for ~~~^� v .................................... � o family dwelling .—.—.--.----.----.-------....--. ' f�ra FieldRmiot \ Location ................................................................cotuit / � ! —,—..----..��.:��::—...°..~--.----. ' �` | George Puz� � Owner ---^��c���.--..�o����.....----..Type of Construction frame ' | \ i ,"" uu [ � Permit Granted~ Date of Inspection'..: ` Date Completed ... , PERMIT REFUSED cv -----_—............. 19 ' ) ^^''—~^-~----'-----'—''—^—^--'-`—'— 1 `^^'--^~--^-----^^^—^'—''—^--'—'—'—'` ! " / —.--.—..........---_..--,.,.-.—�---.. | i '—^^'—~—^—'-----^'~^^''—~~—^'—'---^^ Approved ,--------------- 19 \ ` � . ^ ------------.—.—.—.------.—.— � . . -----------^------'--^'—^—^^'`' ) | ` ^ . CF THE raY Town of Barnstable *Permit# OExpires 6 mo from issue ' Regulatory Services Feeco ♦ BABNSTABLS, s Thomas F. Geiler,Director �ptfD MA't A Building Division O`t Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.bamstable.ma.us Office: 5 08-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �- Not Vafid without Red X-Press Imprint Map/parcel Number 101 /00( � � is� �i/ n Property Address 7 _ l.�c�V� l ❑ Residential Value of Work %�UL�v Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 3'?0 G% 5-4 e_ l CeNt,e ief 01/ L,:.7'v ,, T Contractor's Nam v1 "J/ Telephone Number Home Improvement Contractor License#(if applicable) 63-1 Construction Supervisor's License#(if applicable) C S .3;L-5^ ❑Workman's Compensation Insurance MAR 2 ® 2012 Check one: ❑ I am a sole proprietor ❑ I am the Homeowner TOWN OF BARNSTABLE I have Worker's Compensation Insurance Insurance Company Name �- f� ! Workman's Comp. Policy# wC �' o 3 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) t?rRe-roof(stripping old shingles) All construction debris will be taken to Mv ter. ❑ Re-roof(not stripping. Going over existing layers of roof] ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (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: CLA Q:\WPFILES\FORMS\building permirforms RESS.doc Revised 070 H 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ` Please Print Legibly Name (Business/Organization/Individual):?,qv C'1 _e4t,/t Address: tO 3 ylit t q t tJ _54. City/State/Zip:_ d'I-n-jllc /�'l,0wu Phone #:5L9S 19'�14'11"717 A;'Ipa n employer? Check the appropriate box: Type of project(required): 1. m a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 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 10.0 Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.❑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. tContractors 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. #:_wc n c�- 7 IP Expiration xpira j� �� tion Date: / Job Site Address: 3 7o ►m. 4-e—/l � f_ P—,-,( City/State/Zip: L�U 7'v Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si nature: JCaApae a AZD` Date: ! 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 Pe son: Phone#: CI Property owner Must Complete & Sign This Form it Easing a .Ro®ter 1 Builder. C�AAV_ as Owner / Agent l (print) of the subject property hereby authorizes Paul J Dazeault & Sons Roofing Inc. to act on m Ybehalf, in all matters reive to work authorized by this building permit application for: Address of Job 3 S Signature of Owner Mailing Address of Owner Telephone# Date 1 . C � (Plea se return this form to Cazeault roofing along with your signed contract; It is need ax �8r-u420-4555�n the building permit required,by your town, to complete your°roofing project, thank you ° f i Client#:646400 2NORRISE6 ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/25/2012 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:lithe 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 N A T NAME: Dowling&O'Neil AJC°NN Ext:508 775-1620 ac No).5087781218 Insurance Agency E-MAIL ADDRESS: 973 lyannough Rd., PO Box 1990 INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 INSURER A:Acadia Insurance INSURED INSURER B INSURER C: INSURER D: 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 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. LT R TYpE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MWDD/YYYY MWDD/YYYY A GENERAL LIABILITY CPP005234522 5/03/2011 05/03/2012 EACH OCCURRENCE $1 OOO OOO X COMMERCIAL GENERAL LIABILITY PREMISES ERE Ncccurrence $250 000 CLAIMS-MADE Ex_]OCCUR MED EXP(Any one person) $5 000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO El LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION WCA021246414 WCSTAT 5/03/2011 05/03/201 X U- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500 OOO OFFICER/MEMBER EXCLUDED? � N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT s500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) I CERTIFICATE HOLDER CANCELLATION Paul J.Cazeault&Sons SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1031 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Osterville,MA 02655 AUTHORIZED REPRESENTATIVE C. ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S90861/M90860 LS1 Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5 170 7 Boston, Nlassac- isetts 02116 - Home Improveme�nt'C trac or Reglstratson — Registration: 103714 Type_ Private Corporation Expiration: 7/9/2012 Tr;# 297676 PAUL J. CAZEAU•LT & SONS, INQ:- Paul Cazeault 1031 MAIN ST. OSTERVILLE, MA 02658 .—= �;'• ; Update Address and return card.Mark reason for change. ❑ address Renewal Employment Lost Card s-CAi o 5oon-ogo4-G1oiZi6 �!e �O rrv„tO�LUJEQLLIL iG/ca�ltta --- ''�� � License or registration valid for indi"vidul use only ate\ Office of Consumer Affairs&Business Regulation _ ; _z before the expiration date. If found return to: " �•����, HOME IMPROVEMENT CONTRACTOR OfBce•of Consumer Affairs and Business Regulation — g - Registration:. 0 Type: ` :ram ^1912 3714 10 Park Plaza-Suite 3170 Expiration: 4 " i; — • Private Corporation - - Boston,iVLA 02116 PAOL J.CAZEA11'.1LT ` Paul Cazeault 1031 MAIN ST _ -� OSTERVILLE,MA 0765 =� :_ � Undersecretary Not valid without si�na re 7F Massachusetts -Department of Du'blic Safety iBoard of Building Regulations and Standards Construction Supervisor _ License: CS-026325 PAULJ CAZFA LT 1031 MAIN S - '' OSTERVELI;k Mr1'03655Y " o �f ! J-�^� '�+`�4n'•'` Expiration t I Commissioner 10/20/2013