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0520 COTUIT BAY DRIVE
��� ��� �� a �� __ r.-�,,-,.. -:.�'^, _ .,.',!�.->__. .. _ � _. .Ra. � -ka..�.-ram... -.,...,.,. ....,� - _ : . .. . . - - ,. a t - 3- 1 �7 Town of Barnstable RECEIPT. 0 BAPIvt,ABL& MAIM200 Main Street, Hyannis MA 02601 508-862-4038 .r.3w�� Application for Building Permit Application No: TB-17-3163 Date Recieved: 9/13/2017 Job Location: 520 COTUIT BAY DRIVE,COTUIT Permit For: Building-Insulation-Residential Contractor's Name: Carl J Rebello State Lic. No: CS-084358 Address: , Swansea, MA 02777 Applicant Phone: (508) 567-4109 (Home)Owner's Name: LYONS,JAMES F TR Phone: (203)605-8858 (Home)Owner's Address: 31 FORT PATH RD, MADISON,CT 06443 Work Description: Attic insulation& air sealing. Total Value Of Work To Be Performed: $5,419.00 Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). 1 understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Carl Rebello 9/13/2017 (508)567-4109 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $5,419.00 Date Paid Amount Paid I Check#or CC# Pay Type Total Permit Fee: $85.00 9/13/2017 $35.00 Paypal Paypal Total Permit Fee Paid: $85.00 9/13/2017 $50.00 Paypal Paypal THIS}IS' NOT A��PERMIT Town T of Barnstab e 1 *Permit ,y I 'Fires 6 n ,the fron ss dote Regulatory Services Fee • HMNSTMLE, • Richard V.Scali,Director - Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number QSS � O 3 Property Address 5,,2QC, [Residential Value of Work$o$ �q Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Gc , t-e_k r Contractor's Name a ALE ndi2,J 611 ( /JtSp/( Telephone Number _q0( R�O(� Horne Improvement Contractor License#.(if applicable) / Z3 z L(s Email: Construction Supervisor's License#(if applicable) ('Cj 5 7 O 7 [T<orkman's Compensation Insurance _ Check one: KI DD. Mo El am a sole proprietor E��t.`' egpp ❑ L4m the Homeowner - I have Worker's Compensation Insurance A % JUN 14 2017 FLc' Insurance Company Name' _ A s T"(�'►f'!11�l p NS IABLE Workman's Comp.Policy# We A 31 ,Z�9— 20 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) • ❑ side Replacement Windows/doors/sliders.U-Value y (maximum.32)#of windows #of doors: ❑ Smoke/C.arbon 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 arith other town department rcggulations,i.e_Historic,Conservation,cte. ***Note: Prolre-ty wner must sign Property Owner Letter of Permission. A copy the Home Improvement Contractors License&Construction Supervisors License is require e SIGNATURE: C:\Users\Decollik\AppData\Locai\Microsoft\Windows\Temporary Internet Files\Content.0utlook\21`101 DHR\EXPRESS.doc Revised 040215 I Renewal Agreement Document and Payment Terms byAndersen. dba:Renewal By Andersen of Southern New England Judy Eide =.EL..E...1 Legal Name:Southern New England Windows,LLC 520 Cotuit Bay Drive RI #36079,MA#173245,CT#0634555, Lead Firm #1237 Cotuit,MA 02635 26 Albion Rd I Lincoln,RI 02865 H:(203)605-8858 Phone:866-563-22351 Fax:401-633-6602 1 sales®renewalsne.com Buyer(s)Name: Judy Eide Contract Date: 06/02/17 Buyer(s)Street Address: 520 Cotuit Bay Drive, Cotuit, MA 02635 Primary Telephone Number: (203)605-8858 Secondary Telephone Number: Primary Email: fitfed44@yahoo.com Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows,LLC d/b/a Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to this Agreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement"). Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $18,316 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $0 Balance Due: $18,316 Estimated Start: Estimated Completion: 8-10 weeks 8-10 weeks Amount Financed: $18,316 Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. Notes: Taxes paid in cotuit mass Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s) and Contractor. Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign. YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 06/06/2017 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Southern New England Windows,LLC dba:Renewal By Andersen of Southern New England Buyer(s) Signature of Sales Person Signature Signature Eric Woods Judy Eide Print Name of Sales Person Print Name Print Name UPDATED: 06/02/17 Page 2 / 11 Massachusetts Department of Public Safet j ` Board of Building Regulations and Standards License: CS-095707 - BRIAN D DENNISON 7 LAMBS POND CIRCLE; CHARLTON MA 01507,�--.;. _?> �-1 ",—:-xpir3ti0n: Commissioner 09i08k2018 _'c=4-'-;a __. 'r'?:? �f2 z,*=.'!•:•.fit':;r:,;iSrlc`-rf ... : .:}::-r::�.v.l r.."�•�: >? Office of Consumer,airs and B usiness ReQuiaton' "10 Park Plaza - Suite 5170 Boston;i4lassacht setts 0,21"=5 Home Improvement loatractor Recr;si?ador_ Registration: t i 3245 -' - -- -_--== Type: Supplement Card E:Pirauon: 9/19/2018 SOUTHERN NEW ENGLAND WIND04ti S'LL:; := " BRIAN DENNISON - 3� 26 ALBION RD LINCOLN,RP p2885 - Gudaw.-Wdr_ss and return%art-4tar':mason for cb ngu- ' _Address Renewal _Employment Lost Cant ra: _ zes r _-ORce ui Cnaspmer:VFairs S Basiuev�Rr�,mladoo Registration valid for individual use aniy before the BIOME IMPROVEMENT CONTRACTOR expiration data If found return to: `_ .. or =of C=samer affairs and Business Regaiaeac "'a+ Registration,,-3245 Type: 10 Part:Pt=-Suite 5170 'e-,pirallotr::9j.jq=jg Supplement Card 3rnYuaNLA0311' SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL BYANDERSON'; BRIAN OENNISOPI _- 26 ALBION RD U,NCOLN.Al 02865 '--Undersecrewy Nat v ut signature _ i The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electriciaus/Plumbers. TO BE FILED WITH TBE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/OrganiMion/Individual): F= e doiji-q, Address: 2 A j511_A Irl City/State/Zip: p Phone#: 2>-ffl-- Q Are you an employer?Check the appropriate box: Type of project(required): l XI am a employer with ZO(employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in" 8."❑Remodeling any capacity.[No workers'comp.insurance required.) 3. I am a homeowner doing all work myself 9. 0 Demolition ❑ g y [No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. ❑I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. '' 12.❑Plumbing repairs or additions 47 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.tither 'LJ t r'\,a01 J S 152,§1(4),and we have no employees.[No workers'comp.insurance required.) /Q/�/-a""�—i S *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: 11'e Ole $ f dv r Policy#or Self-ins.Lic.#:C� 31_p 7 Z g — 2- Expiration Date: / f Job Site Address:_ 5 Q nto f 1�Gt�/ �r' City/State/Zip: CpAo'.1- Attach a copy of the workers' compensation policy declaration page(showing the policy number add Apiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the sins and penalties of perjury that the information provided above is true and correct - o Signature: Date. N— /7 Phone#: ZZ.g--T glib Official use only. Do not write in this area,to be completed by city or town offrciat City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: .. Phone#: f ESLERCO-01 SANDERSO .a►�oRO� CERTIFICATE OF LIABILITY INSURANCE . DATEYYYI() os/07120o7i2o17 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT CoBiz Insurance,Inc.-CO PHONE FAx 1401 Lawrence St,Ste.1200 AIC,No,Ext:(303)988-0446 AIC,No:(303)988-0804 Denver,CO 80202 ACE s:COMail@cobizinsurance.com INSURERS AFFORDING COVERAGE NAIC# INSURERA:Acadia Insurance Company 31325 INSURED INSURER B:Firemens Insurance Company of WA D.C. 21784 Southern New England Windows,LLC.dba Renewal by Andersen of Southern New England INSURER C:Liberty Surplus Insurance 10725 26 Albion Road,Suite 1 INSURERD: Lincoln,RI02865 INSURERE: 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. INSRLTR TYPE OF INSURANCE ADDD SUER POLICY NUMBER POLICY EFF MMfDDrfyyn IPO DD EXP uMrrs A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE FX OCCUR CPA3158728 01/01/2017 01/01/2018 DAMAGE TO RENTED 300,000 PREMI E Ea occurrence $ MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 N POLICY❑PE8r LOC 2,000,000 PRODUCTS-COMP/OPAGG S OTHER: EBL AGGREGATE $ 2,000,000 A AUTOMOBILE LIABILITY EOMaBB,INdED e.tlSINGLE LIMIT S 1,000,000 ' X ANY ALTO CPA3158728 01/01/2017 01/0112018 BODILY INJURY Perperson) S OWNED SCHEDULED AUTOS ONLY AUTOS pp BOODILY INJURY Per accident $ AIUTOS ONLY AUTOS ONLY PPe0adent AMAGE $ . S A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ � 1,000,000 EXCESS LIAB CLAIMS-MADE CPA3158728 01101/2017 01/01/2018 AGGREGATE $ DED I X I RETENTIONS 0 Aggregate S 1,000,000 B WORKERS COMPENSATION X PER OTH AND EMPLOYERS'LIABILITY START ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE YIN CA3158729-20 01/0112017 01/01/2018 1,000,000 tWFICER/M�MRIW EXCLUDED? ❑ NIA E.L EA ACCIDENT $ (Mandatory rn N ) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS belay ' E.L DISEASE-POLICY LIMIT S 1�������� B Worker's Compensatio CA3158730-20 01/01/2017 01/01/2018 1,000,000 C Pollution Liability TIEDE664299.117 01/01/2017 01/01/2018 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 17-18 Workers Compesnation Includes-All states except ND,OH,WA,WV,WY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE PQLIEW PROVISIONS. AUTHORIZED REPRESENTATIVE ]FOR Informational Purposes ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION a- m �, ' l.&J, 40 Map D Parcel Application Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address S elO Co f"f BAD Jp.44f_ eo f-A,(1 , K14 o}b3 S Village --*)Owner Address%o i�&t %AJ 1)h 61b, Telephone ;) 03-9q o 31 Permit Request * o S 4 Sipes•. tee o-P w,4004'40 t .�"Crcrcne�-S �� p..i+ �iiSS�a� tUE..SC��a►c� Square feet: 1 st fl r: xisting proposed 2nd floor: existing proposed Total new . Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other n U o aBING `KEPT Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size_Pool: El existing ❑ new size 5 ran: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑existing ❑TneNszeB,�RfOfheri F Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ ' Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION OR HOMEOWNER) C.oainP` oo� Name :no, LCE poi Telephone Number Address y11 `^�6V�n.S��i 1 a�E - License # Home Improvement Contractor# Email Worker's Compensation # VLLn-C y9 I 03�L/n ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Q . rvoM SC SIGNATURE DATE G �'� n • r law • J FOR•OFFICIAL USE ONLY - APPLICATION #_ ` DATE ISSUED MAP/ PARCEL NO. ' ADDRESS VILLAGE OWNER - DATE OF INSPECTION: ;. FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. NOV-11-2016 08:56 FBI - New Haven,CT 203 503 5098 P.002/002 ..a n. 1. L V 1 1 I L.V,i ui 11 U. U; I I r. L Town of Bamstable Regalatary Services m �. Rld uwd V.3M,DhvOor - '� Building Division Paw$oma,Bu ldttag,Comm3smlonw 200 Main SbM lfy�,MA 02601 ' 'ovW town.1MTRftblt.M&= Office: SU-8624038. - Fax: 509-790-6230 Property Owner Must Complete and Sign.This Section J-f Using A BWlder . 7U�C y E vo t .:._,as Oamcs of the ecbject propcq hereby authorize a to act on my behA in 2A MRtxers relative to vozk atdthomed by this bms7d=g P=axtapph=uon for SLo Ut i C34%-, • (AAdte&s ofjob) **Pool fences and alarms are the xespoasiblli of the applicant Pools , are not to be Eled or utilized before fence is installed sad 01 final inspedons axe pedomaed and accepted. l Sigx►"=of Oigcs APP Print Name Rd=Nazbc U1 ®f o17 " Q•FORAdS:O OOPS . TOTAL P.002 t'li l New navun—, Building Sketch th ode I(t3AYDr ice" County gamslable Wta MA ZIPCO40 02035 4Cotu4 rGMM Mo o Services C Xl.s tK� 1 l O�/Ot_i ETEDTO, EVIEWED 70' STABLE BUI ING DEPT. ATE FI .E DEPARTMENT DATE Utility on UUM RMITTING Utility BOTH IGNATU z 13' Lu tN � .,, o o Box &Ldrnt� w (2J4 ft) 15' ti U- N � N w W �• _ Ofo Study ©nth (7 Q z a H z w cc �VQ W p Uj 50' 2 W 00 w w CCOD 00 0 j 56' L 00 w �- W Q ¢ .. Wood Deck b 18' rq lZ' [536 Sq R) 0.. 0 A+ 14' Iq j om co Bedroom Master Beth Krtr,hon uvinp Mrat Floor Cj [2201 Sq Al Bath 13 � Both— y ,. laundry I Dlnlnfl 15' [3DILDIN 1017 EPT Bedroom y 2CarAt:tached Famlly ��� 5 [567 Sq ft] t 28 Cowrod PoreA [112 Sq R] v I ASL� .. TOWN OF F A �S� 28' TA4�Q*chby t-modd�►�inc, A4roa&c�i�l�Mt&1WJent&pSSulnnwh. �MJF`5iE7�9p77A'�41sgIP.+ �� } iwWIIWWWtI� �J ildt T�f� Y511�'1:YI�nWW4UD�++�W�'YWWWWIUIJ+'dIWIWY9A� �s -F!':'UC"."I�bEEG�'��SiBES��67 0a '27�U41WUIWWIWWY�IUGIIIIWWI6l'U3 ft x 2 — 24 L FbOr 2201 Sq 21 x is• ]L' 34 x 50— 17p0 13 k 12 156 2M3 - 6 7�1 Uviing Area �P(( oou�pnnd7IIed)�i p� �� 22al R �u4gv yLn:+Yr.WIYdi71Wlw5ti�IWtYW& �WIW '•: .,,✓'��YI��:11 V" I ouIWW�YWI'•i idll@GNW�+',"�IWUP.IAUIWu6m•1:UIW�IWWIWV° 1�WIW�9CddN v ra 56 MN 446 Dd Deck 536 SQ ft 14 x 2 - 28 3Dx2 - 60 20 x,( 112 er00 Dosch 112 Sq R Department of Industrial Accidents Office of brvestia ations 600 H'dslaing-ion Street Boston, AIA 02111 : Nhi�ri��mass.gov/diu Workers' Compensation Insuran� Affidavit:. ut ctors/FIectricians/Plumbers Applicant information I Luly SeCUCI y ���� Please Print Leeibly 410 University Ave Name (Business/Organirationitudiei.daa)j: e-s , MA 02090 Address: city/state/zip: Phone.#: -1 Are you an employer?Check the appropriate box: Type of project(required): OA I am a employer with 9 �� 4. ❑ I am a general contractor and I 5. ❑New construction , enVloyeds(full and/or paTv ime).* have hired the sub-contractors 2.❑ lam a.sole proprietor or partner,- listed on the attached sheet•_$ 2 ❑Remodeling ship and have no empjoyees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp:insurance. 9. ❑Building addition [No.workers' comp.insurance 5• Cl We are a corporation and.its required-], officers have exercised their 10,E]Electrical repairs of additions 3.❑ I am a homeovwver doing all work right of exemption per MGL 11..❑Plumbing repairs or additions myself. [No workers' comp. c..152,§l(4),and we have no. 12.0 Roof repairs insurance required_] i employers. [No workers` comp, insurance required-] 13.[l Other boa s Any appb='r fhat cb=lzs box-#1 must also fill oui the section below showing their workers'compensation policy infbrmffu n. 74omeowners who Subrrnt this affidavit indicating they are doing all work and then hire outside contraciors must submit a new affiidmit indicating such. rs ntracto that check this box must anached an additions]sheet showing the name of ibe sub-contractors and their worker'•camix policy information. 1 iun an employer that is providing workers'compensation insurance for fi#employees. Below is ilte policy and job site information- Insurance Company Name: A A m t rZ G��� i•t C:L J� ��C.t �,c--S���A�`� ` Policy#or Self ins..Lie. : W L YL G t-/Q I o 7 Expiration Date: /b� I I I Job Site Address: .Sap &T-W City/StateJZip. & 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 off MGL c, 152 can lead 1b the imposition of criminal penalties of a fine up to S1,300.00 and/or one-year imprisonment as well as 6i,a1 penalties in the form of a STOP WORK ORDER and a fine of tap to$250.00 a day against thP,violatbr_ 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 h y certify under the pa s and : rs of pPdwy that dze it formation provided above is frue mid correct S• store: Date: / a i Phone : ? 4'l i S:f- S �f Official USe 01!1)L ;Do not write in this area,to be completed by city or town gf�iciai City.or Tovvm Permh/License# Issuing Authority-(circle one): '1.Board of Health 2.Building Department 3_City/Town Clerk 4.Elecirical lnspector 5.Plumbing Inspector 6.Outer Contact Person: Phone#1: - { 7 ® DATE(MM/DD/YYYY) A`o CERTIFICATE OF LIABILITY INSURANCE F09128/2016 .� 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). CONTACT PRODUCER NAME: Marsh USA Inc. PHONE FAX 1560 Sawgrass Corporate Pkwy,Suite 300 c o A/c No Sunrise,FL 33323 E-MAIL ADDRESS: Attn:FtLauderdale.Certs@marsh.com INSURERS AFFORDING COVERAGE NAIC# 048953-ADT-GAW-16-17 INSURER A:ACE American Insurance Company 22667 INSURED INSURER B:Agri General Insurance Company 42757 The ADT Corporation ADT Security Services INSURER C:ACE Fire Underwriters Co 20702 1501 Yamato Rd. INSURER D: Boca Raton,FL 33431 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003442307-09 REVISION NUMBER:1 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 I ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY XSL G27858703 10/01/2016 10/0112017 EACH OCCURRENCE $ 2,000,000 [TAGE-TO RENTED CLAIMS-MADE M OCCUR PRREM SES Ea occurrence) $ 1,000,000 X SIR:$500,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY PRO LOC PRODUCTS-COMP/OP AGG $ 41000,000 JECT OTHER: A AUTOMOBILE LIABILITY ISA H09050991 1010112016 10/01/2017 COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WLR G49103347(AOS) 10/01/2016 10/0112017 X STATUTE I ER AND EMPLOYERS'LIABILITY B Y/N WLR C49103359(T ) $ N 1010112016 10101/2017 2,000,000 ANY PROPRIETORlPARTNER/EXECUTIVE E.L.EACH ACCIDENT C OFFICER/MEMBER EXCLUDED? N/A SCF C49103360(W)I 10/01/2016 10/01/2017 2,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under 2,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION ADT LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn:TOM LEE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 410 UNIVERSITY AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. WESTWOOD,MA 02090 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee _YtiCstuar��+ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Tom Lee SS-001779 - License Number: Status.: Active Renewal Id: :.:. Profession: :Regillated-Activity i : :`License Type: Security Systems=:S=I icense . .:..:... PP :.IssiieDate: ::OS/I.6/2012 I:astRenewal; 04/201201C: E uah xp. :: �n Date: .05/16/2018 .: Commonwealth of Massachusetts Department of Public Safety License:SS-0o1779 AVA Security Systems-Serer THOMAS J LEA �L g 410 UNIVER-51TY0 y, z WESTWOOD UA•�-QW- �o vs :�Ilfi1b Expiration: Commissioner 05/16/2018 Employer:ADT Security Systems-S-License DPS Licensing information visit: WWW.MASS.GOV/DPS 1 I. �� 3•;=t OMMONWE ILTFi OF MkS5ACHUSETT.S <>: > EtETftfCIANS ";:ISSUES TE�LLOWING LICENSE AS A ::. . . R (STERED SYSEIUF('Ali1TRAC. OR'.. . 774aMAS J.LEE' _ - ,z ' ADT'iLC L18A=:Ap <SECURITY < 410 UNIYER$3Y AVE WESTVVbgp,'MA -020;"-! ''" 172~ '' 0?�31120�9 122173 �Y CAUTION:CARBON MONOXIDE GAS AND rrS DETECTION D(PORTANT:This deteetm should be meted and maintained This carbon monoxide detector is designed for indoor use only.Do not regularly following National Fire Protection Association(NFPA)720 Honeywell expose it to rain or moisture.Do not drop the detector or subject it to requirements(Generally,this detector should be fully tested at least other physics]shock.Do not open or temper with the detector an this aao°per month) may cause it to malfunction.The detector will not protect against the MAINTENANCE 580000 Carbon Monoxide Detector with Built-in Wtreless Transmitter risk of carbon monoxide poisoning if not properly Installed. NOTE:The detector will only indicate the presence of carbon hOccasionally the°onto the e farm casing with.shah Enema that the Installation and Setup Guide monoxide gas in the vicinity of the detector itself Carbon monoxide �°s oa the hunt of the alarm era not blotted with dirt end dual Table 1:Detector LED Mod" ratt y ty be present In other areas• Do not point,and do not we cleaning agents,bleach,or polish GENERAL INFORMATION THIS CARBON MONOXIDE DETECTOR IS NOT- an the detector. The 680000 is a 8V hattery-powered whelese Carbon Monoxide(CO) Green LED Red LED Sounder detector intended for use with wireless alarm systems that suppart Normal Blinks every Off -Off Designed to detect amoke,fin or any gas other then carbon DETECTOR REPLACEMENT 58W series device n s.Comult your control pael's installation (standby) � 10 sees de monoxi • A substitute for the proper servicing of fuel- • liances or This dement is manufactured with a lang•Bfe carbon monoxide atiom for compatibility. trobcideAffect Off Blinks every Temporal 4 the sweeping of chimneys b�m8 appliances seaser.Over time the sensor will lose sensitivity,and will need to be compatible Compatible Controls Tuts detector lien be used with t support series I see pattemt • To be used ce an intermittent basis,or as o portable alarm for the replaced with a we carbaa monoxide detector.This detector's carbon m e adde so(Listed to UL884 and/or UI.986)that support e spillage cleombustion products from fuel-burning apDliantta or likapen is approximately six years from the date of manufadum. carbon momxide some type and utrlize a 6881 receiver. Low Be" Off Blinks every Chirps every 46 chimneys The user shouts The detect=mneists of an electrochemical carboy.—..;do duster 46 sees for sees beginning Carbon monoxide gas is a highly poisonous gas which is released. ���'check the check the replacement date. assembly coupled to a wireless transmitter.The transmitter coot send 97 days 7 LED b inter Bemoan the detester from its ease sad cheek the ndi replacement dam LED blinks, when CaeL are,burned.It is invie3le,has a smell and is therefore label m The underside of the detector.The label indicates the dam alarm,trouble,endofliC4 temPor,and battery condition messages to continues SO impossible to doted with the human se ses.Under normal conditions that the detector should be replaced. the eyemm's receiver.Refor to the w-nelem ayetem's instructions for day. in a room where fuel burning appliances are well maintained and the maximum number of transmitters that tan be supported: correctly ventilated,the amount of carbon mona dde released into the NOTB:tYban the detector is removed t}om its bees,a message is seat NOTICE:These instructions should be left with the ownerfuser of Test nol Gm Hoicks every Off Off room such a to the a is etetion-H tee system is erased,a tamper Berm Ted 1 see by ppliencen should not be dangerous. this equipment message ie•enh if disarmed,a trouble mewage i•wet SYMPTOMS OF CARBON MONOXIDE POISONING:Carbon t 4 I The detector weft also indicate a trouble condition when it bee DCPORTANT.This detector moat be tested and maintained Fumetion°l flee Off Blinks every Temporal monoxide bonds to the hemoglobin in the blood and reduces the reached the and of its useful life.If this aware,it is time to replace regularly following NFPA 720 requirements. i sec parrots co is dispeasso amount of oxygen being circulated in the body.The following the detector. WARNING:This product Ili not intended for use in industrial sympto are related to carbon monoxide poimmng and should be NOTE:Before replacing the detector.notify your central station that factories or cammmcal parking garages. Detector Trouble Off B�every One 46 s every ms discussed with all members of the household-. maintenance is being performed and the aydem will be temporarily • Mild exposes-Slight headed, muse,semi DETECTOR DESCRIPTION.,_ Detector Endob Off Blinks every One chirp every ling.fatigue(often out of service.Disable the mac or system undergoing maintenance t •JVLieted to UL standard 2076'z .' Iafa 10 seer 45 ease described as'fiu-like"symptoms). prevent any unwanted alarms Dispose of detector in a�rdmee with =CO�mctivity iaevehiated to UL 2094 Off • Medium expoeme:Sever throbbing headache,droweineee, nay loc.,regulatimne. Power Up Blinks every Blinks every confusion,fast heart rate. CAUTION Supervised 10 wwtt 10 sees" Ertreme erpwurs:Unconsciousness,mnvoldons,cordio It should be noted that installs' . Loc.1 asunder (weed L®) Mw•en LSD) respiratory failure,deatti. torment than meting and mointenmca of the 6BWC0 is different then smoke detecmn.Per • Ihul LED. 1 Temporal{petters is a repeated series of d short beeps tllowod by Many causes of reported carbon mmoxide poissaing indicate that NFPA 720 section 5.3.7.2 the detector etdl rot be concealed to e tom • Ted/Hoah button 'a 6 ace pause-H ambient eanditimm return t mrecaL the CO while victims are aware that they ere net well,they become se that signals a fire condition(Le.emoke detector canes).Therefore,the . Functional Gas Ted detector will switch ham Alarm mode to to Prevleus made. disoriented that they aro enable to save themselves by eithor,exiting 6=00 detector must be programmed ere a non-fire some.See the tt Red and green LEDs blink a total of 4 times,once every 10 aece- the building ar calling(ar assistance. central panel's Installation Instructions for the appropriate carbon Outface mount ll wall ar waling Also,young children and pets may be the first to be affected. n omode sons type to be programmed. • Optional drywall anehors included minaHush(entire:H g the Tey,the audible alarm redcl silenmd ter 6 The 68o000 contains a piemeiedrie hem which generates the ANSI minutn by pushing the temporal 4 p t button.The red alarm light will Q SPECIFICATIONS 89.41 temporal 4 pattern in m alarm conditian(see note below Table 1 cansmc to erase I. mute h d pattern If a audirbanble monoxide te still WARNING:DD?ORTANT INFORMATION IrOH THE USER presentHu after the win hush period,the above slam will(pa wand. Aduation o(y°ur CO°later indicates the presence of carbon Power Souroe:One 9-wit CR189A Lithium Battery(included). fora eat to the of the temporal 4 he detecl Ito alarm%a message is The Hush[stare wkB not operate at levels above 860 Dpm(parts per monoxide(CO).which can cause injury ar death (Replace with Duracell DL128A,Pama°nie CR128A or ADEMCO else east t the control prod and the detector's cam Dumber fe million)carbon monoxide. 4663 displayed at the mneds The alarm message is transmitted every 4 Trouble features When the sneor eupervi®oa is I.a trouble Individuals with medical problems may c°nmdet using warning Audible S rem mtil the carbon mode condition ban cleared and the detector Signal(temp{tote):86 dBA min fro dorm(at 10ft) conditiaa,the detector will end a trouble signal to the panel The red devices which provide audible and visual signals far carbon monoxide Hetgbt 2.8 imts(59 mnn) ban renal During an alarm condition pressing the deteeto's LED blinks once every five secs Trouble°anditiom include lid opt concentrations under 80ppm. Diameter.5.8 inches(185 mm)with mounting base TedlHush button will silance the piezoelectric horn far 5 arinuten. dreuit causes.removal(tamper),and sensor and of M. Went to do If she carbon monoxide detector goer Into B Weight 7=(241 g)without battery Once the detector has reset a RESTORE message ta transmitted to End of Idfe T1m°r vesture:When the detector has reached the and 1. Push the Hu bloat butts Ifthe detector reactivates or therm:e Operating Ambient Temperature Range: the central panel and the transmitter's zone number can be cleared cline life,the detector will send a trouble signal to the panel.This detector does not silence,continue with Step 2. 92'to 100-F(0'to 87.8'C) from the pace indiestm that the CO semnor inside the detector has pained the end 2. Immediately move to fresh air,outdoors or by an open window. Operating Humidity Ranges The detector's base accommodates a variety of methods for mounting- °(it life and the detector must be replaced.This dded e.lifespan Check that all persons are convected for.Do not reenter the 16%to 95%Relative Humidity,m a—d°n ing it approximately six yearn from its date-of manufacture.Refer to premises nee mave away Goes the open do°tfwindow until Agency Elating.UL standard 2075 Two LEDs and a somder an,the detector provide local visual and Detector Replacement sadism of thin manual Patent Numbers:7.120,796 Low Battery Demettom The 680DOO is powered by a single 8-volt emergency service responders en teas arrived. audible indication of deteeor'e statue as listed in Table I. 8. Cell sal local fire department bum a phase is m area wren the Pbese see Invert for Unnita0oro of Carbon Monoxide Detectors. CRI29A or DLy at l Lithium buttery(included)-The detector etecte ks eu in seta During initial power-up,the rod and green LEDs serf blink together Tao a knv battery at least every 86 minutes.Ha low belfry is detected. 4. ISyour detector reactivates within a 24-hour period,repeat steps once every 10 ace four times It taken about 80 nets for the deteco'e the transmitter sedds a low battery message to the antral panel, 1.9 and call a qualified tpp6enty technician to investigate CO sensor to stabilize(see Table 1). which beeps and display,the detedaes ran°number.In addition,the possible nour°ra of CO bum fuel burning equipment and FOR WARRANTY INFORMATION AND FOR DETAILS REGARDING detacton.red LIED will blink every 46 ante,Agar 7 days,the detector'. epplieneee,and check for proper operation of tbie equipment H THE LIMITATIONS OF THE ENTIRE ALARM SYSTEM,GO TO: After power-up hoe completed and the detector is functioning hero will',h r ebe d every 46 aces(red LED continues to blink)for problems are identified during this inspection.have the wwwJxmeywe 1.°°nJsecurl mes/wa normally.the green LED blinks once every 10 sees.The LED up to So days-Preening the Test/Hush button during this time will equipment serviced immediately.Note any combustion equipment indication must net be used in place of the mete specified under ailenoe the chirps for 12 hours,if no other trouble conditions exist The not inspected by the technician and consult the manufactuuee. TESTING THE DETECTOF_ battery should be replaced BEFORE the chirps begin.Be sure W instructions or mntant the manufaetuu°re directly,far come replace the battery with a bash me. information about 00 safety and this equipment Make sure that motor vehicles are not,and have not been,operating in an This device eomplica with Part 15 of the FCC roles,and RSS210 attached garage or adjacent to the residence, of Industry Canads Operation is subject to the following two omditi°me:(1)This device may not cause harmful interference, and(2)This device meet accept any interference received, II Honeys fell 2 Corporate Center Drive,Suite 100 including interference that may cart°°undesired operation. II I II II II I IIIII II I I I II II II I II�II J•` P.O.Box 9040,MetvIIIe,NY 11747 Unauth°rixed changes or modi6estiom mold void the uses K14631112 4114 Rev.A Cop do d o 2ao7 a hner.d kftrecl.W k nuthonty to operato the equipment. 4r BATTERY INSTALLATION AND REPLACEMENT MOUNTING THE DETECTOR - 1b replace the battery: First,determine the beet Is etion far the detector,me that provides L Remove the detector from its mounting base by twisting the proper oath=monazide detection(see Figure 4 for suggested ®� detector counterclockwise.Remove the battery and dispom of detector locations)and a strong w•aeleas tranemteeioa path. -.:•_:•. ..:. ..: property. proper Carbon Monoxide Detection Location -- t] O 2.7b ensure proper power-down sequence,wait a minimum of 20 In a well lontion,the de should be at least as high an a light co axrsrr seco before installing new battery. switch,and at lead 8 inch from the ceiling.In a ceiling location, Flpure L Mount DeteeMAtapss Cegfrtg Panel Support ��" •~0 EWW A Install a new 8-valt CR12aA m DL12aA Lithium battery in the the detector should be at least 12 inches from any wall m\��F&art= wens err OVAMErEA battery compartment.NOTE:Follow the polarity diagram inside Where to Install.kl 1M• DO NOT attach Ore detector o as shove os0trg poneb.Attach the battery compartment Within 10 feet of all sleeping areas Qre detector across parcel support ns ettowrr ht Fgure 9. amaorv, 4.Retnetall the detector anto its mounting base by turning the Inside the bedroom if it contains a Awl burning appliance CAUTION detector clockwim On every Door of the building Airborne dust particles eon enter the detector.Honeywell Figure A Repassed Test Button Opening 6.Test the detector as described in the TESTING SIGNAL Ideally,install in any room that contains a fast burning appliance tecommmds the removal of detectors before beginning construction STRENGTH section of this manual.The green LED should blink ifthe appliance in the room to not normally used,such as the on any other dnsbprodudng activity.Carbon man®do detectors ere TESTING SIGNAL STRENGTH about men every 10 ern to iadicete normal cpemft If the boiler room.the detector should he placed Lunt Outside the room so guardsnot to be used with detector e the combination bee beenNOTE:Remove battery tab before installation. battery is not installed correctly,the defector will not operate and the stares can be heard more easily evaluated and found a far that purpose. This test should be performed hekM tnntellaimtellatim to determine a the battery may be damaged.H the detector does not appear to be Where NOT to Insta4 Ideally: strong communication path with the neutral panel.The test should sending a signal during any of the testa,check for correct battery Detesters operate hest when installed 30 feet or further from any . installation and for afully charged battery. be repented after des signal is complete.least w the ywnerluear corking epp}lage should feet the unite signet strength at least weekly. Dimetly above a sink,cooker,stove or oven •.Neat to a door ar window that would be affected by drafts is. ■ L Activate the wireless sy,tem'e GOING GO TEST mode from the wmsoms ertceeWr fan or as vent smmou keypad Oefw to the control paners instruction mnauAD- ,w,0 Outside ■ 2. Depress and hold the detectors THertHUSH button.H the •Do mt install in any,environment that does net comply with the detector has not previously sensed a low battery condition and is ✓�j detectors mvummental eyedfiCOU010e se� era operating within proper sendtivity limit,•it ahmld immediately apenam� In or below a cupboard transmit an alarm signal to the control panel The built-in horn •Where as Dow would be obstructed by curtains or faniture ■ will start to sound about 2.6 sc s after pressing the button. r,pf Where dirt on dust could collect and block the seaeor oo°�rn A The wireless,system'.keypad should emit at)seat 8 tones when uuaus Where it could be knocked,damaged•or inadvertently removed the alarm transmissim is received and will display the GOOD TRANSMISSION PATH ■ transmitting dateeWre some number. Figure 1.WWC0 ftelass Carbon Moncrlde Detector A GOOD TRANSMISSION PATH MUST BE ESTABLISHED FROM s' " 4. When the control panel her received the test signaL release the THE PROPOSED MOUNTING LOCATION BEFORE TESMHUSH button.The hors will stop and a few eOwnda later PROGRAMMING PERMANENTLY INSTALLING THE DETECTOR To check, the detectors one number will clear from the Console display. The detector must be enrolled in the control panel before it too perform the test described to the TESTING SIGNAL STRENGTH Figure 4.Detector Location Diagram 6. ifthe console does at respond as described above: Operate in the system.Alarms and trouble conditions tam the section.)him to mounting the detector to the mounting ban.you TAMPER PROTECTION a. Make sure the battery is installed with the Correct Polarity. detector are reported an can protection cane,which is programmed as must enroll'the detectors serial number into the system(see the This detector has a built-in tamper ewfteh that will ceum a CHECK b. Make the battery is hash, carbon moaeride won typo(erne type 14 for Honeywell residential PROGRAMMING-diar). to he at the console of the alarm if it to the detect"to signal displayed a9etom' H this is m initial installation,try moving contrah).lam Table 2 for the types of events reported. Mounting Procedure removed from its mounting ban while the system is disarmed(alarm another location that provides proper reception.Alm be aura Table 2•Ersnd and Their ID Codas Once a suitable location is&and,moaat the detector as follows occurs if eyet=is armed).The 580000 detector includes a tamper, that the detector has bem'enmRed'by the control panel(see Event Alpha Keypad CS Report 1.Refer to the diagram below and instoll the mounting ban an the resistant fo ter,that prevents removal from the mounting base PROGRAMMING).Then.repast the signal ebeogth t-L 7's co Alarm 00 alarm CID I6 coiling or on the wall(it local ordinances permit)using aerew without the use of a tool.To engage the tamper•residaut feature,cut test CO Alarm 00 alarm CID 1 locations'A'or oW as required.Use the two acrews and anchan the email plastic tab located On the mounting base Qrigure 2).and 8. O off the eyetomb PEST mode from the keypad(security code law bad L Bat RP low-belle CID 984 provided.Men-uver the base so the screws are at the elbow of the then install the detector.lb remove the detector Gam the ban age • detector 1.Trouble RP senior low-battery (superCID 3 ,mew dots and secure' it has been made tamper resistant.use a small screwdriver to TESTING PROGRAMMED LOOPS se .aim CID 881 2.Fit the ddeetar inside the base by aligning it over tho base as depress the square tamper release tab,located an the skirt of the detector and-of life CO Trouble sego"trouble•mdcf• ahown(detectora alignment notch should be slightly offset from mounting base,and turn the detector couaterolaclrwida This test should be performed before installation to ansom that the detector trouble life CID ggp mounting ban tamper release tab).than turn the detector in a FUNCTIONALLY TESTING THE DETECTOR detector has been programmed and is operetienel in the system. clockwise direction until it efinb.into place. 1. Activate the d vel s TRANSMITTER ID SNIFFER mode from temper disarmed= RP sensor tamper N07E:The 6g0000 detector must be meted alter i de which The CO Trouble (CID 889) A Test the detector after completing the iastellatim(m described in G80000'e features include a Pnncfland Ors Tut mode which eon be too keypad(see the control psnei'e instruction manual).AD the TESTING THE DETECTOR section of this manual.Refer programmed winless were will be displayed,me by me,on the armed= used r verily the detector's as ability to sense carbon momsida gm.1b 00 Alarm co the nOntrohe an ofe fireless ievi tar additional information perform the functional gas teat,follow,then etepn: system keypad.Make ern the detector cone is displayed b ed in the I.Enter the onatrors yam Programming mod-. concerning the an of wireless devioea L With a small screwdriver,depress and hold the recessed �ue�•ro(If nct•rsed.) that the detector won her been 2.Enter the alarm woe number to be programmed. rnurrw, IWMush switch for apptorimately 2 secs.The detector will properly P��ed•) S.Enter the applicable soon type when Prompted.Use sore type 14 oouusct temporarily wand in steno and the red LED will illuminate 8 With the detector mounted tm The Wee the mounting ham.d wiessth the for Honeywell residential controls. �. 2. Within a few cam•the green LSD will start to Wink rapidly. damdma ehouldT&rl disappear saps from the keypaassociated m theennert display 4.When prompted,inter Input Type Oa(8 an same controls)— indicating the detector is in functional test mode.At this time, cycle.This mean that the vydtom has received a transmission Supervised RF Transmitter. the unit is waiting far the user to dispense the test 00 sample. from the detector one you he"programmed. 6:Wbm prompted for the serial number,do the following O a. Spray a very small amount of Sob"'C6 canned CO toward the A Wham testing is complete,ester the Installer code+the OFF a. Remove the detector from its base(rotate the detector a gas entry ports located at the center of the detectors(nnt fens .. count—loekwise an the base until it snaps open). em 0 sO�p's (se at left in Figure 6).Selom 06 is available through many key to eat TAT mode. s, es NOTE:Detector must be removed from its ban to enroll , sonm1Bro security equipment vendors. When,11 system tasting her been completed,notify the central b. Prase the detectors Testillueh button twice Qer each prone. ® �' pm try monitoring station that the system is back m line. 4. U etanenaflil gee m and if functioning DnParly.the hold the button down far several secs). 0�) detector will begin sounding in a temporal pattern and the red e. Reinstall the detector Onto its ban(twist the detector LED will blink.An alarm signal is sent to the panel,providing clockwise until it amps into place). userm°eorwraeocr.goo© verification of the alarm signal d. Check that the detector is enrolled as loop L acowmnaa—acme 6. The-term condition at the detector will Stop after 20.60 sees, I,DeltuR�iM9RL•LI &list Programming mode when programming is complete,and feet �anr�ssaya �^p man nnora or when the CO gas has cleared. the detector.Refer to the Testing Section of this document. ",s'wro 8. Hgm entry to unsuccessful,the teat will automatically and after See the central unite installation instructions for man details. 27 seea Ffgufe L Mounting the Defector —2— s' Maintenance � Honeywell 5808W3 Photoelectronic Smoke/Temperature NOTE:Before performing maintenance on the detector,noti'the 10. Reidstall the ba Detector with Built-in Wireless Transmitter N ty ttery into tfa battery compartment noting proper proper authorities and the contml station that maintenance is being orientation.The red and green LEDs will Raah once every 6 performed and the system will be temporarily art of service.Disable seconds for approximately 20 seconds until the porver-up cycle is INSTALLATION AND SETUP GUIDE the was or system undergoing maintenance to prevent any unwanted complete. alarms,and follow this procedure exactly,referring to Figure 5. 11. Reinstall the detector and teat(see the Testing section). 1. Remove the detector housing from the base by twisting 12. Notify the central station when the system is back in service. General Information Two LEDs and a sounder on the detector provide local visual and counterclockwise. DViPORTAW..U this procedure is not followed exactly,the audible indication of the detector's status: Before installing detectors,Please thoroughly read these installation 2. Remove the battery from the unit detector may indicate a maintenance trouble after the powerup instructions and Guide for Auper Use of System Smoke Detectors Table 1:Defector LED Modes S. Wait 20 seconds.(11)ensure proper power-dow i sequence,the sequence is complete.If this happens•remove the battery for 20 (A05.1003-002),which provides detailed information on detector battery must be removed from detector for a minimum of 20 seconds and than reinstall. spacing,placement,zoning,wiring,and special applications.Copies Piezoelectric seconds before continuing to the next atep.) Green LED Red LED of this manual are available from Honeywell. Nora 4. Remove the detector cover by turning counter-clockwise. osiecrce tU aaw I NOTICE:This manual should be leRwith the owner/user of Power Lip B Inks Every Blinks awry OR 6. Vacoum the aver or use canned air to remove any dust or debris. this equipment. 6 see 5 see ' 8. Remove the top half of the saeedseaxirig chamber ( ) b7 hitrng 1 (ravaur) - 10 see straight up(see Figure 5). IMPORTAND This detector must be tested and maintained re Norval s Blinks every On On 7. Vacuum or use canned air to remove any following NFPA 72 requirements. Blinks every are duet or particles that ' ere present on all chamber sections. General Description Out of Sensithrily On 5 sec On S. Replace the top half of the saeenteensing chamber by aligning 4 The 6808W3 photoelectronic amoke(heat detector with built-in Freeze Trouble On Blinks every On Press the arrow on the screemfwnsirg chamber with the arrow on the wireless transmitter is intended for use with wireless alarm systems 10 sec using.Ps down firmly until the srreen/sensing chamberia that support 6800 aeries devices. Refer to antroVm comunicator 'Blinks every fully seatod. oCrzaron,eusna installation instructions for compatibility. The 5808W3 oke/ Smoke Alarm On t sac Temporal Pattern, maker B. Replan the detector cover by placing it over the screen/sensing sonrao heat detector can be used with any 6800 series wireless receiver/ Blinks every chamber and turning it clockwise until it snaps into place. Figure S.Removing Screen/Sensing Chamber transceiver for residential installations.For commercial installations, Thermal Alarm On 4 sec Temporal Pattern the 6981ENHC or the 5883H receiver is required.The transmitter con send slam.tamper,maintenance(when central panels are equipped BliI -_nks every Chip every 45 to maintenance signals),and battery messages P Ba tte ry On sec attar LED process sign tlery condition m es to sec 1 blinks for 7 days Specifications I the.yntom a receiver.The maintenance sigael fully complies with the sensitivity test requirement specified in NFPA 72,10.4.4.2.4 and.is During initial powerup, the red and green LEDs will blink Power Source: One 3-volt CR123A Lithium Battery(included).(Replace with Duracell DL123A,Sanyo CR123A, approved by UL Refer to the wireless system's instructions for the .synchronously once every 6 seconds.It will take approximately 20 Panasonic CR123A or ADEMCO 466.) I aaximum number of tremmitters that can be supported. seconds for the detector to finish the powerup cycle(see Table 1). Haight: 6.3 inches(13 ram) The 6808W3 incorporates a state-af-the-eft optical sensing chamber After Diameter. 6.3 inches(19b nun)with mourtiag base jDti cog pou'psnp has completed and the detector is functioning normally . Weight 8.5 oz.(241 g)without battery 1 and an advanced microprocessor.The microprocessor allows the within its fisted sensitivity range,the green LED blinks once every Operating Ambient Temperature Range: 320 to 10(rF(0°to 38°C) I detector to automatically maintain proper operation at factory 10 seconds.If the detector is in need of maintenance because its Operating Hunudity Range: 0%to 9b56 Relative Humidity calibrated detection levels,even when sensitivity is altered due to the sensitivity has shifted outside the listed limits,the red LED blinks Heat Sensor. 1350 F Fixed Temperature Electronic Thermistoro presence of contamiaeato eetUin�g into the unies smoke chamber.In once every 5 seconds.When alarm has been activated by smoke,the Freeze Warning Sensor. __ 41'F.(6"C).- _.. .-► - order for this(cature to work properly,the chamber most sever bs red LED blinks every 1 second.During a thermal alarm condition AgencyLietings: UL 268-Commercial and Residential Installations opened while power is applied to the smoke detector.This includes} (>1360F)the red LED blinks onto every 4 acconds.The LED indication cleaning,maintenance or screen replacement.All models also feature must not be used in place of the testa specified under Testing.In a a restorable,built-in,fixed temperature(1350F)thermal detector and freeze trouble condition,the red LED will blink once every 10 seconds is also capable of sensing a pre•freeze condition if the temperature is (refer to Table 1).H the detector senses a low battery condition,the j - Please refer to insert for the Limitations of Fire Alarm Systems below 4PP.. red LED blinks once every-45 seconds. The 5808WS contains a piezoelectric ham which generates the ANSI 1b measure the detector's sensitivity,the M Series Model BENS-RDR Fos wnarNarr trsoaeusvxx2 uo our+oEraxs sEoaaoaut rNE twrrn71or2s 7tkE eamtE,unau sysrrx aEVEe m THE wsuturnn ucsmucrgts con THE S3.41 temporal pattern in an alarm condition.In alarm,a message LArared Sensitivity Reader tool(see Figure 4)should be used.Refer to aECEivEnicOataot rink wnxau rws DE"M is Cusco. is also seat to the wireless Control panel.The alarm message is instruction manual D100-BB-00 for proper use of the SENS•RDR trmemitted every 4 seconds until the smoke or heat condition has s cleared and the detector has reset During an atom condition. Low Battery Detection rnh eo.im-0."ta vm is d or FCC linesw aas2lo w hdi yCnman oamdlm h rvs)ed m m ma,nap n,o w,dliu,c TW nvrna ewes n.maw t+.,luarca utl M rah dwks��wl kdmiu rosco"mtivsag � (p codes I pres®ng the detectors swi tch itch will silence orn the piezoelectric h mrr ewae a,e.s`xa wwdmn The 6808W9 is powered by a single 9-volt CR123A or DL123A Lithium rro ores eWvnm°wc"awwlaasrs'°a°coo°s°'a'meu"u°`u'°r°ww°'a'pss w nmdoraawam mv s for 6 minutes.s.On the detector has resale a RESTORE message is transmitted to the control panel.The buiWin Drift Compensation des Mme`ewrydm battery(rncluded).The detector checks for a low battery at least i algorithm automatically maintains the sensitivity of the detector, every 65 minutes.If a low battery is detected,the transmitter sends Once the detector reaches its limit of ampensation,it transmits a e low battery areesege to the control panel,which baps and displays the detector's zone number.In addition,the red LED of the 5808W3 Honeywell maintenance signal the panel.The mounting base installation is will blink every 45 seconds and the test.witch will be disabled.This I simplified by the incorporation of features compatible with drywall fasteners or other methods that provide a-method for securing the condition will exist fora minimum of 7 days,and than the detector's detector.in place. horn will-chirp-about every 45 ascends.Pressing the test switch during this time will silence the chirps for 12 hours.The battery 2 Corporate Center Drive,Melville,NY 11747 r should be replaced BEFORE the chirps begin.Be sure to replace the CopyriBMC 2007 Mosul ea Intemaaonal tm battery with a fresh one. www.hmmyw&OXIisecudly . b1o0-10o-00 166-2768-005R •1- i Battery Installation and Replacement 6. When the serial number is displayed,transmit from the detector Deal covers are an effective way to limit the entry of dust into the C.Direct Heat Method(Hair dryer of 1000.1500 watts) a second time by activating the tamper switch again as described smoke detector sensing chamber during construction.However,they To replace the battery: in 6tep 6.The current loop number(4)will begin to Rash. may net completely prevent airborne duet particles from entering the Direct the heat toward either aide e f Be sure to hold the 1. Remove the detector Imm its mountingbase twisting thedetwour 7. Manually change the loop number to the desired loop number far detector.Tberefore,it is recommended that the detectors be removed hunt source shout la inches from the detector ctoorr to avoid damage to the the zone(accordin to the o location). before beginning construction or other dual producing activity.When plastic.The detector will meet Only after it hag time to cool. counterclockwise.Remove the betted;and dispose Property. 8 PP S. When programming for this tone is complete, m other returning the system t service,be lure to remove the duet covens Smoke detection testing is recommended for verifying system 2. To ensure proper power-down sequence,wait a minimum of 20 Progro g P PT09r'O from any delectore that were left in plow during construction. ' seconds before installing new battery. =rice for the transmitter as necessary(except for Tamper Loop protection capability. 3. I-tnll a new S-volt CR123A lithium battery in the battery 4,which does not require programming). Smoke detectors are not to be used with detector guards unless the A detector that fails to activate with any of these tests should first be compartment Follow the polarity diagram inside the compartment. WARNING:The fire protection rune enrolled most always be combination has been evaluated and found suitable for that purpose. denied as outlined in this manual's MAINTENANCE section.If the 4. Reinstall the smoke detector onto the mounting base by turning Loop 1.Otherwise,fire annuMiations will not be reported by the Tamper Protection detector still fails to activate,return tar repair. the detector clockwise. control. 9. Exit Programming mode when programming is complete,and This detector has use a built-in tamper switch that will come,a CHECK Testing Signal Strength 6. Test the detector as described in the TESTING SIGNAL last the detector.Refer to the Section. - sign displayed system STRENGTH section of this manual.The green LED should blink 1°g al to be die le d ti the console of the alarm if it la NOTE;Remove battery tab before installation. about once every 10 seconds to indicate normal operation.If the See the control imies installation instructions for further details removed from its mounting base.The 6808W3 detector inductee o I tsmper•resisw cc nt feature that prevents removal from the mounting This test should be performed in accordance with NFPA 72 inspection, battery is not installed correctly,the smoke detector will not Mounting and the battery maybe damaged.If the detector dam not First,determine t eat base without the use of a tool.7b engage tyro temperrcreistant feature, testing and maintenance requirements to determine a strong operate be sending a signal during ed.of the testa,cheek for he b location far the smoke detector,one that cut the small plastic tab located on the mounting base(Figure 2).an com munication central path with the cenOl panel. appear a correct battery installation and far a fully,charged battery. provides a strongwireless transmission path and r smoke then install the detector. si remove the detector from the base epnest PO props 1. Activate the wireless aystom'e GO/NO GO TEST mode from. detection.AGOODTRANSMISSION PATH MUSTBE ESTABLISHED has been made romper resistant,sae a smell screwdriver to depress the keypad. FROM THE PROPOSED MOUNTING LOCATION BEFORE the square tamper release tub,treated on the skirt of the mounting PERMANENTLY INSTALLING THE DETECTOR Te check,perform base.and turn the detector counterclockwise. 2. Depress and hold the smoke detector's TEST switch H the defector has cot previously detected a low battery condition TEST sv�tCtk the teat described in the TESTING SIGNAL STRENGTH section of Testing the Sensor and it is within proper sensitivity limits,the detector should this manual.Prior to mounting the detector to the mounting base, immediately transmit an alarm signal to the walml panel. you meet oenrolls the detector's serial number into the system(see NOTE: Before testing,notify the central station that the smoke The built-in horn will etmt to sound about 2.5 seconds after the PROGRAMMING section).To mount the detector,perform the detector system is undergoing maintenance,in order to prevent depressing the button. O following steps: unwanted alarms. OMEN LED following The wireless eyetenr's keypad should emit at leas[three audible 1. Once a suitable location has been determined, install the During initial powerup,do not use SENS•RDR or tamed smoke to sounds when the alarm transmission is received and will display mounting base on the ceiling or on the wall(if local ordimnees test the detector.The SENS•RDR and canned amoral can be used the transmitting detector's zone number. atEo LED permit).Use the two screws and anrhore provided. after powerup sequence has completed.Detedare must be tested 4. When the console hoe received the test signal,release the TEST 8023sa0 2. Turn the detector in a clockwise direction in the mounting base after installation and following periodic maintenance.The 5608WS mid,The ham will immediately step and a few awards later Figure 1.58DOW3 Wireless SmokeMeat Detector until it clicks Into plum. may be tested as follows: the detector's some number will clear from the console display. Programming S. Test the detector immediately after completing the installation A.Twt Swttch l 5. If the muscle does not respond as noted,check the polarity of the (as described in the TESTING section of this manual)and refer battery and be sum it is fresh.If this is an initial installation, The smoke detector must be enrolled in the control panel before it can to the control system's instructions for additional information I. A recessed test switch is located on the detector housing(sea .try moving the detector to another location that provides proper operate in the system.The 6W8W3 smokethmt protection wee must concerning the use of wireless smoke detectors fi�r'O d)• I reception.Also he sure that the detector has been'enrolled'by be enrolled ae Loop 1 and'Input Type'3(supervised'RF). macrwua- 2. Push and hold the recessed test switch far a minimum of,6 the control panel(see PROGRAMMING).Than,repeat the test seconds.Use a smell screwdriver ar Allen key with maximuC & Turm off the system's TEST mode from the keypad(security If programmed,this smoke detector is capable of monitoring the diameter of 0.18 inch(the atartn panel will triggerend then the additional conditions of Maintenance(transmitted w Loop 2).and r code r OFF). make detector will go into alarm.It the tool is removed from the Testing Programmed Loops Iota Tamperewre(transmitted u Loop 3) Tamper is tran®itted o recessed switch the sounder will shut off) no Loop 4,but does not require programming.To take advantage of the value added features of Maintenance and Low Temperature,you If the detector is within the listed sworrid limits.the LED an This test should be performed before Installation ram ed to ensure that all must program web Imp as a wimante wine in the 5800 aeries wireless • the detector should blink once per second and the hum should loops intended to 6e used have been Programmed and are operational compatible panel. n+okn urersAsena xT„"'��'m:n sompm round SMONhin 3 NSm A in the system. "Oa'�' POSO AL AREAORfl ATAN ANGLE ON 1. Enter the control's Zone Programming mode. THE�m,Ta+ n I 1. Activate the system a TRANSMCPI'ER ID SNIFFER anode from WORD 2 Enter the was number to be programmed. un Figure 2.Detector Mounting Base the keypad(s the control(mrrol's instructional.All programmed wireless canes will be displayed.one by one,an the system 3. Enter the applicable cone type when prompted.Program keypad.Make sum all make detector tunes are displayed in •Loop I(Heat/Smoke)an a Fire race(type 9 or 16), the sequence.(If they ere not,recheck that all woes haw been •Loop 2(High/Low Maintenance)m a 24•Hr.Trouble tune(type TEDTD property programmed.) TEST oo end BvmcN rtecEssEo 2. With the detector mounted to the bracket.Preen the smoke 3(Freeze Warning Sensor)u a 24•Hr.Aux.cane(type 8). are c"tvu A Smmaa detector'.TEST switch AR wrces associated with the smoke LOOP LED pAMETEN IDOL detector should disappear from the keypad an the next display NOTE:Loop 2 HighR w Maintenance is supported only on ell such as the Vista-128FBP. Figure 4.Recessed rest Switch Opening and SENS-HDR PasitiOn cycle.This mama that the system Ices received a transmission control pen sorupas from each loop you programmed. 4. When prompted,enter Input Type 03(S on mine controls) B.Smoke Entry Teat I S. When testing is complete,enter the Installer code♦the OFF key -Supervised RF Transmitter, to exit TEST mode. 6. When prompted for the serial number,transmit from the defector Figure 8.Mount Detector Across Coiling Panel Support A conned smoke agent may fa used to teat the detector.Rater. the ry 8 y manufacturer's inatmctiona far proper sae of the canned make.HSI When all stem testing has been completed,notify the central station by activating the tamper switch.Tb do this,hold the boss of the A DO NOT attach the detector to removable Ceiling tamed smoke has been tested and approved for use with this g that the system is back on line. detector in one hand,.and rotate the detector counterclockwise panels.Attach the detector across panel support as on the base until it maps Open.Then ream to clockwise position shown in Figure 3. type of emoke detector. until the detector maps into place. i Town of Barnstable *Permit# 12 (oT < rvi Ex res 6 from t!10ate Regulatory Seces Fee e • •ax�vsrnet a Thomas F.Geiler,Director puss. �oa ••� Building Division �R Tom Perry,CBO, Building Commissioner QCT 200 Main Street,Hyannis,MA 02601 2 4 2007 www.town.bamstable.ma.us T Fax: 508-790-6230 IA R`YSS PERMIT APPLICATION - RESIDENTL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ()5$p 3 K Property Address �5 20 (�Oki (.y Uf, Co/yi Residential Value of Work 4/ Uzi Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �T;/ Pet, 4111 10 Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's.License#(if applicable) ❑Workman's Compensation Insurance . Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ® Re-roof(stripping old shingles) All construction debris will be taken to tf ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *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 rovement Contractors License is required. SIGNATURE: i ,per The Commonwealth of Massachusetts �\ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111' w0w.mass.gov/din ' Workers'Compensation Insurance Affiddvit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): J�'�' �y a-7 •Address: Stun° — f3k y City/State/Zip: fi -L-��� °2C 3 Phone.#: Are you an employer?Check the appropriate bog: :Type of project(required):. I.❑ I am a employer with 4. [] I am a general contractor and I 6. ❑New construction . employees(full and/or part time).* • have hired the sub-contractors 2.❑ I am a'sole proprietor or partner- listed on the'attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• Demolition �Vorkin for me in an capacity. employees 3 and have workers' g y p tY• 9. ❑Building addition [No workers' comp.insurance comp,inc„rance.t' 5. We are a corporation and its 10.❑•Electrical repairs or additions requited.] officers have exercised their 11. n re I am a homeowner doing all�work . right of exemption per MGL � O Plumbi• g airs or additions p myself.[No workers comp. 12•®Roof repairs 07z- PW insurance.required.] t c. 152, §1(4),and we have no d 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 Homeownes.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 ornot those entities have employees. if the sub-contractors have employees,they must provide their workers,comp•policy number. I i nm an employer that is providing workers'compensation insuraneefdr my employees. Below is.the policy and job site, information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: ' Job Site Address: J �0 •ca 7v�� g�� {��- City/State/Zip: �7tiiT O�G 3 S Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure,to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK,ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the.Office of Investigations of the 1)IA for insurance coverage verification. _- I dohereby certify under the pains an enalties of perjury that the information prov Date• ided above is true and correct. Si afore: �� x _ Phone# � Official use only. Do not write in this area, 0 be completed by city or town official City or Town: ' Permit/License# Issuing Authority(circle one): A.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: •Phone#:' .�`Y"`'• TOWN OF BARNSTABLE Permit No. N,Un.0 . Building Inspector ...16 - y,-• - `" Cash "- ------------------ OCCUPANCY PERMIT Bond,. No building nor structure shall be erected, and no land, building or structure shall be used for.a new, different, changed; or enlarged-,use without ;a--Building Permit;-therefor first having been obtained from the Building Inspector. No building!sliall•be.occupied until a. certificate of occupancy has been issued by the Building Inspectors\' Issued to Cotuit Bay ShoreS Realty Tr, Address fit\ lot 49,,( E. { 5.96 cotni t- Rau T)r•i yp. rntt t i.t' f Wiring Inspector / � { 3nspfection date` Plumbing Easpector + �llR" l Inspection.date;� Gas Inspector W J " � l {/ V - Inspection date X Engineering Department �/ � Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. 19 ? /� j.. ............. ... .. ...., � .....�.�.�. BuildingjInspector _._._................ � N \ N o-n /. G ` Y61G �11 •'i�i'Y •, Lr,�+.•�� .lL v'�, tl.c .mil '6... N. , JOJV V` o tt .y✓ Wqt.TE,. jVJ OF cy w. `�•�. p'� GRETE G� M. BOHANNON 106 - ND Su / hereby certif that stokos hovil?p ~'" been•set os shown on June".24,1/980 t ` PL O T• -PCA N, and tf at the /ocotion•confor ns"to.,, A` the Zoning By Lows of they Town-of'. k\ Barnstable. Foundation,".wo//" 0 /ocatio ,: confirmed on July 2_l$80 �� a �' -- COTU/T . BAY. SHORES COTU/T BAJRNSTABLE, MASS. Sco%e�-/'' 46' f t; June 25, /980 �a BOHANNON LAND SURVEY CO. Owner: COTU/T •BAY..SNORES, INC. West Brid�ewo 'e�, 'MASS. 02379 t Assessor's map and lot number 5 ..... t a�.. ..... SEMC SYSTEM MBE,,- c, Sewage-Permit number ... ........................................... IN UST , S'fALtEp IN COMPLIANC FE • � ?M E t� �� � O � E 5 ` OWN OF/ BARN". ��' CO �WN R DE ANC 22 REGULATIONS i BARNSTOBL& i Mb 9 BUILDING INSPECTOR O�G YPY a' i a APPLICATION FOR PERMIT TO .........construct a dwelling.............„•...... TYPE OF CONSTRUCTION aingle...f.amily waod..Ir me..................••...•....•......•....•....•••• i ..........June...1.7...................19... 80 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a, permit.according to the following information: Location .... Lot 26 Cotuit BaX Shores_.. Cotuit BA j.V.q.•„••.................................. ..... ..... ..... ......................... Proposed Use ...sing, ... .>eaideric6.......................... ......Fire District CO.tuft.................................................. Zoning District ............RF...............................:................. ............. Tr. Cotuit Ba Shores Realt Name of Owner .......................X...................................Y/....Address .. 2.:�t....Z.sabella..J3,oadr...Cr�tui ....... Name of Builder ..Cotu .....Ba.y Shores....................Address ..........Saxi3a.......................... Name of Architect ...R0y.d1..t3c Xy...T9Iil15.................Address ...6. Newbury S.t...'i—B©st©n•i...MA............... Number of Rooms .........7.......................................................Foundation .......poured...can.Cr:e.to............................... Exterior .....Wood fr..,mQ...................................................... I� ........................ ........as asphalt.......................................................... Floors ..Wood. f toors -..mej, ...dwe.l.ling............Interior .....wa.11s...—..dr-Ima•11./.skim...=at............. Heating4...4j.1...f1r.ed............................Plumbing ...........ger:...oo.de................................................... Fireplace ......................Y.eS....................................................Approximate Cost ....$80•yQ0.0................... Definitive Plan Approved b Planning Board ---June--2a 19.7-a--. Area ......��y ..La ............... Pp Y 9 - - - t-------- - Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH /l�0 .4t l.hereby.agree'to. conform.to.,aJl.?he..,flu.le.s...Ant!_R.eplg igp _of_the Town.of.BarnstaE le_C gorc�j.�.g..,the.aboue�......:.,' construction. COTU T BAY SHQRF�S�/R-AALTY TRUST Name •R18 ark' f '15'e I sari KiIT i 'Tr-usteeA COTUIT BAY SHORES REALTY TRUST No ... Permit-for ' One Story .................................... Single Family Dwelling ................. Location. ,Lot. #.2.6....5.2.0...Cot.u.i.t...Bay...Dr,. .. .... .. . .. ..... .. ................C-otu-it................................................ Owner ...C.o.tui.t...B.ay Shores Realty Trust . .. ....... .. . .......................................... Type of Construction .......Kra.me......................... .... ..... . ................................ ................................................ Plot ............................ Lot ............. .......... Permit Granted ...........................June 2-3,................19 80 Date of Inspection ...................�4.1.30..19 Date Complete,91 ...T**................17Z... 19 PERMIT REFUSED ................................................................ 19 ....... ......... ... ............................ ................ J ...... .. .. .... ...... .. ................. ..... ......... ....4-1 �. . . . ....................... ................ . .................................................... Approved ............................................. 19 ............................................................................... V&V 7 Assessor's map and lot number r`' 1 •h—, �� Sewage Permit number .................!..... ................................... ,yl °fTHE T `TOWN OF BARNSTABLE • Z BARNSTABLE, i "6 9 BUILDING INSPECTOR ��YPY p'• APPLICATION FOR PERMIT TO .........construct...a...dWj.7.»g............................................................... TYPE OF CONSTRUCTION .................aingle...f.ami.lyy.--wood..Brame:................................................. ........... une...17...................19....80 TO THE INSPECTOR -OF BUILDINGS: The undersigned. hereby applies for a permit according to 'the following information: Location .....Lot 26 COtuit Bax••Shores•.• COtu•it•.B�y••Dx•jwe.•••••••••••••,•••„ ProposedUse .... $a. ...family...residence............................................................................................................. Zoning District .............V........................................................Fire District ............GO.twit.................................................. Tr. Name of Owner COtu .•t•••Bay..Shores Realty/••••Address ...�32..P?t....Isabella...R,oadr".catui.t....... Name of Builder ..COtt]•�t..aa.Y...S1 or.es....................Address ..........SAMP................................................................ I J , Name of Architect ....RQya1_13arry..Willa.................Address ..b..Newbury...S.t.,.T.•BOsto.n.,...M............... Number of Rooms ........7.......................................................Foundation .......p.Onred...cotricrete............................... Exierior .....W990 ra ,,2....................................................Roofing ........asphalt.......................................................... Floors wood..f,19PKS... TRaIA...dtel ing............interior .....walls...m..drywa.1.1/.skim...coat............. Heafing cU.1'.fired............................Plumbing per..code........:.......................................... Fireplace ......................Y.eS.........................................•...........Approximate Cost ..... 80. .00.0............................................. Definitive Plan Approved by Planning Board __JU21e__2S_#--------19.23__ . Area .......................................... Diagram of Lot and Building with Dimensions Fee. ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH 1 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. COTUIT BAY SHORES REALTY TRUST Name 'i2ici��'r�d"'T�'. "D2'"P�ncpY><�:2'is; "Trtxate COTUIT BAY SFeORES' EALT A=55-38 No 2.229.5.... Permit for One story .........slag p-..k�m Iy...Dx�lling............ Location ....Lot #26 520 Cotuit Bay Dr. ........................................................... Cotuit ............................................................................... Owner Cotuit Bay shores Realty Trust ................................................................. c•x f Frame Type of Construction ........................................... Plot ............................ Lot .. ............................. Permit Granted .......June 23...................!..... 19 80 Date of Inspection ......... . .,......19 Date Completed ........................... .......19 PERMIT REFUSE ................................................................ 19 ................................ .........../. .0 ................. ' ...................... ......................... PA.". ..................... Approved ................................................ 19 ............................................................................... ...............................................................................