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HomeMy WebLinkAbout0361 TURTLEBACK ROAD C� I cAA-c ALTERNATIVE WEATHERIZATION a Date ` Town of Barnstable 200 Main St. Hyannis, MA 02601 Re: Permit#_!J The insulation work at _ has been completed In accordance wit1t-;780EMR'-i Agency work performed'for .`R'etls - Cj --a '•'i' • , .. .•.'. N Timothy Cabral;':;:';!., ' President co n CSL-105454 v, rn NJ 58 DICKINSON STREET FALL RIVER,MA 02721 (508) 567-4240 ALTERNATIVEWEATHERaOONOGMAIL.COM -_- -- , - - --- - -, -_ ---- b__ r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # ` LIS 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 Village Qrx+m ,, S Owner J�&6114l it X)0,1 sAI AddressA/ ur'f/e6a Telephone L-e 44J0 J Permit Request r Id L J6 - V'�' P,,h o) ff ��S e A_LJ t3`Uwt- f)o-r 4-a - Square feet: 1 st floor: existing 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 0 Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: 8U z T, C w Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ n W Commercial ❑Yes ❑ No If yes, site plan review # 'p, Cn Current Use Proposed Use - w M [co' i APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name f/ Telephone Number JOO7'T� Address K License # M 6 702/ Home Improvement Contractor# 6 Email /lei t 9) ,� Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FF^IS PROJECT WILL BETAKEN TO ' A)&v 4y SIGNATUR DATE �` `(� FOR OFFICIAL USE ONLY APPLICATION # o DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL z PLUMBING: - ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. • _ t 1 ti(j� Imo'l4K H.a•I..b_.. I At THE p Town of Barnstable coo ;, ' �' °� Regulatory Services aAPUNST ALE, : Richard V. Scali, Director ice. C 9�0 1639. Building Division �TEB MP't A. Paul Roma 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 1, JENMFER WALSH as Owner of the subjectproperty __._.................----..............__........._.._.....__............................._..._........_........._..._._................_...................._.._.........._._....__..__._........... J . hereby authorize ql� 1�pl,�bllP I �Mp�J to act on my behalf, in all matters .relative to work authorized by this building permit application for: 361. Turtleback Road Marstons :Mills, :MA 02648 -.-... (Address of Job) ��—a� 31� ______I-___.._..._._._.ture C� Date Print Name It Property Owner is applying for permit,please complete the Homeowners License.Exemption Form. C:\Users\decollik\AppData\Local\Mitrosoft\Windows\INetCache\Content.Outlook\L7U69LF2\EXPRESS(2).doc 01/25/17 I - y The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual):ALTERNATIVE WEATHERIZATION, INC. Address:2 LARK STREET City/State/Zip:FALL RIVER, MA 02721 Phone#:508-567-4240 y Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 16 employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capaci�.[No workers'comp.insurance required.] 9. ❑Demolition 3T�I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.[]I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole l l.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.- 14.�✓ Other INSULATION 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:STAR INSURANCE COMPANY Policy#or Self-ins.))Lic`.#:0849�2�5700/ h,�, I � ,mow! Expiration Date:4/4/18 Job Site AddresLI6 _7 !ra _ e LJ'C.L6k /�C`I _ City/State/Zip: �15t Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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. I do hereby certify unde dh , ins an allies p rjury that the information provided above is true and correct Signature: Date: l Phone#:508-567-42 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ALTEWEA-01 SNERONNA ACOR,D' CERTIFICATE OF LIABILITY INSURANCE DATE(MMl00rcrrY)05126/2017 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 endorsemen s. PRODUCER NT cT Christine Costa Mason&Mason Insurance Agency,Inc. we°N a Extl:(781)523-0067 jAIAC,No): 458 South Ave. £ IL Whitman,MA 02382 ccosta asoninsure.com INSURE S AFFORDING COVERAGE NAIC 0 INSURER A:Evanston Insurance Co. 35378 INSURED INSURER 13:SafetyInsurance CompanyI39454 Alternative Weatherization,Inc. INSURER C:Star Insurance CompanV 118023 2 Lark Street WSURER 0: Fall River,MA 02721 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: I 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 CONOI'TION 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 LTRTYPE OF INSURANCE AOOL SUBR POLICY NUMBER POLICY EFF POUCY EXP LIMIT A I X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 I IE CLAIMS-MADE I ".00CUR 3C42088 06/07/2017 06/07/2018 DAMAGE TO RENTonil s _ 100,000 MED EXP(Any one persom S 6,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I S 21000,000 PRODUCTS-COMPIOP AGG S 2,000,000 POLICY�JET i LOC i OTHER: B I AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT I S 1,000,000 (Ea accident)ANY AUTO i 6237702 04/08/2017 04108/2018 BODILY INJURY Per erson) 5 OWNED SCHEDULED l BODILY INJURY Peracadant;� AUTOS ONLY X AUTOS yyNN pp � X ARE ONLY X AUOT��ONLV Pe�aUitle It IMAGE 5 A I I UMBRELLA LJAB X OCCUR EACH OCCURRENCE 15 1,000,000 EXCESS CLAIMS-MADE OBW661961fi 06/0712017 06107/2018 AGGREGATE i S 1,000,000 I DED RETENTIONS S C WORKERS COMPENSATION X PER I OTH. !STATUTE AND EMPLOYERS'LIABILITY YIN WC 0849257 00 04/0412017 04104/2018 600,000 ANY PROPRIETORiPARTNERIEtECUTIVE n E.L.EACH ACCIDENT 5 FFICER,MEMBE 1 EXCLUDED? N N!A 500,000 Mandatory iIt NH) E.L.DISEASE-EA EMPLOYEE S It yes,desonbe under !i 600,000 DESCRIPTION OF OPERATIONS beALv E.L.DISEASE POLICY LIMIT S.POLI l i I DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Addttlonal Remarks Sehedula,may be attached If more space Is requiredl Action Inc.and National Grid USA,its direct and indirect parents,subsidiaries and affiliates shall be named as additional insureds on Commercial General Liability policy per terms and conditions of forms CG2010 and CG2037•and Commercial Auto Liability policy per terms and conditions of form SCA 005(02 16).Forms Available Upon Request. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN National Grid ACCORDANCE WITH THE POLICY PROVISIONS, 40 Sylvan Road Waltham,MA 02451 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD � � Ge�s^sl`r�iifQn•Sri�e's�Sscx . W M .. k ZLI a Office of Consumer Affairs and Business Regulafion 10 Park Plaza - Suite 5170 Boston, Ma,00usetts 02116 Home Improveme"caritractor Registration r� - - }^ __ Y='= Type. C rpomdon RegLqUa3ion: 175683 ALTERNATIVE WEATHERIZATION,INC a , r 2 LARK ST ; r Explranon: 05/28/2019 FALL RIVER,MA 02721 Update Address and return card. Mark reason for change. SCA 1 0 2C:M-05'1' ed .a s (1 Renewal I7 EMPIOMMOt ❑j_Qat, aryl o. '%�>ie: C;r:in1!trlrtLel1��/t Y3!':%��d&:N.7riirtr:Ct! Ot i.of Consumer Affairs&Business Regutalion HOME IMPROVEMENT CONTRACTOR Registrabon valid for individual use only i V .TYPE:Corporation before the expiration date. H found return to: Ot19ae of Consumer ANadrs and Business Requisition OwW2019 10 Park Plaza-Suite 6170 ALTERdATIVE NEY. 1fl INC. MA 02116 s TIMOTHY CABRA.L%70�„., ,j FALL RIVER,MA 02721; A Undersecretary -_ 8ttlre r Town of Barnstable *Perini Expires 6 mo om LzW_Q ate Regulatory Services Fee S. $ Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town_barnstable.ma us Office: 508-862-403 8 Fax:.508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address 36Z 24�6E4K Aoom`lz;4T JU Residential Value of Work 5�00,�/ Minimum fee of$35.�000 for work �under$6000.00 Owner's Name&Address SC—/�.� /Ui4l M/L Contractor's Name Telephone Number �7 G�3 t7�QcJ Home Improvement Contractor License#(if applicable) 97 O� Construction Supervisor's License#(if applicable) �+► Workman's Compensation Insurance Check one: 'lUN 212013 FT am a sole proprietor ❑ I am the Homeowner ��N �] I have Worker's Compensation Insurance VV 01r Insurance Company Name BgRNSTABCE Workman's Comp.Policy Copy of Insurance Compliance Certificate must accompany each permit Permit Re est(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris-will be taken ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side L #of doors ❑ Replacement Wmdows/doors/sliders.U-Value _ (maximum.35)#of windows ❑ SmokelCarbon 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 air -SIGNATURE: _ 11AMSrasr s. • '� ,0 Town of Barnstable Regulatory Services Thomas F. Geiler,Director Building Division Thomas Perry,CBO. Building Commissioner 200 Main.Street," Hyannis,MA 02601 www.town.barnstable.ma.us " Office: 508-862-4038 Fax: 508-790-6230 Property'Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject ro . � • l P Pay hereby authorize �G�GC�.G/�% �i✓5���/G%/G7�s% to act on my behalf, in all matters relative to work authorized by this building permit application for. 361 l vierz47 t5 fi-r-K (Address of Job) W* ef Owner Date Print Name If Property Owner is'applying for permit,please complete the Homeowners License Exemption Form on..the reverse side. QAWPFM\FORMS\building permit foi4mMPRESS.doC - °FTti : Town-of Barnstable Regulatory Services BARNSTABLE, ' Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200-Main Street, Hyannis,MA 02601 www.town.barnstable.m.a.us Office:. 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village ..HOMEOWNER": ' name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home'in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to-the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such'work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with-the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and.requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 15,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner perfdnning work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the-homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for- Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name(Business/Organization/Individual): 7�G0•����� D1�S77tt/GT��'� Address: City/State/Zip: S' Fe0'Vr Al if hone#: Are you an employer?Check the appropriate box: Type of project(required): 1.91 I am a employer with V 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp.insurance.# required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑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 13.❑Other employees.[No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. L/ Insurance Company Name: Policy#or Self-ins.Lic.#: or Expiration Date: Job Site Address:v 4/ '—1 rZ6 � P7w � XD City/State/Zip: i(�l 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 ceraV under the ' and penalties of perjury that the information provided abov is true and correct. Sip,nafore: Date: h �cJ JIV Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy Mi formation(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia CERTIFICATE OF LIABILITY INSURANCE F05/01/2013 UA YYI� /2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(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 PAUL SCHLEGEL Schlegel & Schlegel Insurance Brokers Inc NAM . FAX PHONE (AIC,No,Est): (508) 771 - 8381 1(A/c,No):(508) 771 - 0663 34 MAIN STREET E-MAIL ADDRESS: SCHLEGELINSURANCE@VERIZON.NET ADDRESS: PRODUCER CUSTOMER ID d: West Yarmouth, MA 02673 INSURER(S)AFFORDING COVERAGE NAIC tI INSURED INSURERANGM INSURANCE 14788 Adilson Segolini Dba Segolini Construction INSURERBGRANITE STATE 117 Minton Lane INSURER C INSURER D: West Barnstable, MA 02668 INSURER E: i INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SR LTR TYPE OF INSURANCE INSR VWD POLICY NUMBER PO C EFF PO C P LIMITS (MWDDNYYY) (MMIDDNYYY) A GENERAL LIABILITY MPT8486U 05/07/2012 05/07/2013 EACH OCCURRENCE $1,000,000 DA AG10 X COMMERCIAL GENERAL LIABILITY 05/07/20 05/07/2014 PREMISES(Eaoccurrence) S500,000 CLAIMS-MADE Fx-1 OCCUR MED EXP(Any one person) $10,000 PERSONAL B ADV INJURY $1,000,000 GENERALAGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO JECT LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accident) ANY ALTO BODILY INJURY(Per person) S ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Peraccident) S NON-OWNED AUTOS S $ UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS UAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION S S B,. WORKERS COMPENSATION AWC 702602501 05/23/201205/23/2013 X WcsLATu oTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOWPARTNERIEXECUTIVE 05/23/2013 05/23/2014 E.L FACH ACCIDENT S 100,000 OFFICERIMEMBER EXCLUDED? ❑ N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD tat,Additional Remarks Schedule,if more space is required) ADILSON SEGOLINI HAS ELECTED COVERAGE FOR HIS WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION NONE ON FILE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REFIi SENT 19 -20 9 CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD ------- ....._._..... a License or re istratton valid for mdiv�dul use onl . Office of Coosumerff9 rs&Business egu a� g n Y HOME IMPROVEMENT CONTRACTOR betore the expiratwn date Ifff6um return-to Registration: 159597 Type: t�.: Offce of Corrcu er Affairs.aA Business Regulation• Expiration: <$%1!5L2014 DBA a.': 10 Park Plaza Suite 51.70 S t,:.. Boston,MA`02116 S LINI CONSTRGT_ION�11 1 ADILSON SEGOLff_4I= w 117 MINTON LANEt`,���= : '�'-� = '. ' WEST BARNSTABLE:Mi4 026liA a"Y -- \.r— y- Undei"sec?eta _5 rY *. vq1 wi out signature IVlassxchusctts- Dcp.1rmien"f Public S:►fch g�tar-d_ot• BuildinO Re4ulxtions aril Stan( ir( Construction Supervisor Specialty License.. License: CS SL 99907 Restricted to. RF.WS,DM ADILSON SEGOLtN,I ' 0•1�` ,; 117-M,INTON:LANE1 rW�ST� STABLE •MA 0266,E Expiration: 1 011 4/201 3 _. Tr#::5207: . I i Assessor's map and lot number ` / SINE 3 q - 9 S�17D IC-- Trl Sewage. Permit"::number ......................................................... . Z O33AR33TA DL House number :" /� a ...................................... i639• ' D NO y. TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO !...:.!�!�'fi�!r(vr ��G /_ %I /?9/4� / G=J%;/J�'v r= TYPEOF CONSTRUCTION ....... .................................................................................... 19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Locations ;4? . .'7.�...........1..tJ h�l�- ,(3 i 1;........ .............. 1?? "" ....... �.:.. ................... .............. F ProposedUse `:...... ..a..i3...-r........ (n E E... ................................................................................................. �G!Ii�d A.?'I�A-'tr Zoning District ...�.(./-.........r........:..............................................Fire District .............................................................................. Name of ....................................Addresst.. w,,.i,,t. nr?. ...��4Kriz./ .PkA.............. p,r ,.?I�.. ! h-.�r�J.3 .�!. f�.....Address ., r :F .d.r� f. l >� ,,;. Name of Buildert;�'t. ...� �..` ,, . .. ... .. ••••••••• Name of Architect 77..................................................Address °.. Number of Rooms (I Foundation .. <;?:!"*?f .r4........................................... i Exterior M.1 �T.�.�"r.i? .n-.....:f•y;�n� .!. t........... Roofin f/1tf4-y7 �f�/ip %:`'.......................... <..�-F... g .. .................................... . .... ,..a.� . �,/ ao a�,�. '".......................Floors !. Interior ..'T-N �,�aA-! ......................................... Heating .................>d.............................. .... ............Plumbing..... ....................................................... .. Fireplace ��.�i1�a ,., r7II//l. t� Iii•P/i1 ........................Approximate. Cost �S �'o..!1tJ............?�.. ....................................................... Definitive Plan Approved by Planning Board ______ i!----------19_7—. Area " .. . ....... 11 Sus Oil, Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH ` M -^9 ` 4 ytv` `E OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to 'conform to all the Rules and Regulations of the Town of YBarnstable regarding the above construction. Name ..�................. ...................................... .� (,� Construction Supervisor's License ... .....,/�...........,t......... READY, MIKE A=63--43 A 27296, One Story No .. ............ ... Permit for .................................... Single Family Dwelling ii Location ...Ipt....371 36.1...Turtleback Road ...... ...... . ........ ............. ...... Marston Mills ............................................................................... Owner ..fie..Ready ................................................ Type of Construction .....Frame ..................................... ............................................... ................................ Plot ............................ Lot ................................ Permit Granted .....................December 3, .........19 84 Date of Inspection ....................................19 Date Completed .................................... /19 ,J10 7ue 5A4,,AeJ t4�-1 17 pp a / Assessor's map and lot number 3 f'THET Sewage Permit number ...............................................:........ d � Basa9TnnLE, House number �3 • MM6 ' TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .......................... /Win'« �f�'"��,D��v TYPE OF CONSTRUCTION .......4:V PO.....611t,! ?'7 .................................................................................... ...............................1.. .I:F7r9..�r TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: �. ........... �. �.......�..1..:.. �f..�. 5.. .............. �(�' � �. Proposed Use 1:A('Y! ..�.�C�!''l.F ......G'v��!'IV E/�;--E . ................................................................................................. �. Zoning Districtag&?U&rh+;: ........ �. ...................Fire Dist(r�ict .............................................................................. Name of Owner1—%111.( 4X--tP.y...................................Addresst-(,.�ltOvr. i ,,.... � ............. Name of Builder °i13. .. SP..FYahr. � �.d' .....Address fr .1r-... .1 .. �f I� ,f.............. Nameof Architect ..................................................................Address ....... ......................................................................... Numberof Rooms ........ ......................................................Foundation .......................................... .w-r.c.aasto. .....ff3 /14G .r P........................Roofing .,.., y f Q ?.... f/ 1 1?..................... Exterior ..... Floors ..... ... `.,1�!.j!t�. j�l�fT .................................. Interior �t� .�rL ''"...................................................... Heating .........oe.!.. . ....................................................Plumbing ... ......................................................... Fireplace 4� (�LI7l. . ��l� . .IO�/N.lP6�'l!?�..........................Approximate Cost .......:;. f.. ....................... ,.... • f�'f�d ��"� Definitive Plan Approved by Planning Board _____'�g9kllr_.-------19_ Area Diagram of Lot and Building with Dimensions Fee ..��..................... SUBJECT TO ,APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ................................ Construction Supervisor's License ...(;.-.f� 2—Y'dP'.(e........ READ7f, MIKE No .................27296 Permit for .........One.... ........Story.............. ......Si le. -Ecwn-ily..Weuing........................ Lot 371, 361 Turtleback Road Location ................................................................ Marstons Mills . ............................................................................... Mike Ready Owner .................................................................. Type of Construction Frame................................ . ........ . ................................................................................ Plot ............................ Lot. ................................ December 3, 84 Permit Granted ....................... ..................19 Date of Inspection ....................................19 Date Comp; d, ................19 v 18 - 11 zLe� µ �oT57 Shown oQes no - o'�ai-� aKj rrcis�1►''� 1�C ✓ �Q lO�1 o T 7�E" /o wn 1/1 WALTER y� O -� P. OLDHAM N #23207 SSTt U R Y1 N . o' Vl . 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SOIL S T'R A rA r ' TOWN OF BARNSTABLE BUILDING DEPARTMENT = ssearr = TOWN OFFICE BUILDING rua .639. `� HYANNIS, MASS. 02601 MEMO TO: Town Clerk FROM: Building Department I DATE: An Occupancy Permit has been issued for the building authorized by Building Permit $ . ...... — -= ... .. ._ :.... ....._.._................... issued to Please release the performance bond. IV,*X S TOWN OF BARNSTABLE Permit No. -------27296 Building Inspector Cash 161 OCCUPANCY PERMIT Bond Z Issued to Mike Ready 9 Address. Lot 371, 361 ,Turtleback Road. Marstons Mills Wiring Inspector Inspection date. -7 Plumbing Inspector Inspection date k"Gas Inspector Inspection date -49 A x Engineering Departmt�lt: Inspection date -7 Board of Health Inspection date kv 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 AND IN ACCORDANCE WITH SECTION 119.10 OF THE MASSACHUSETTS STATE BUILDING CODE. 119.9 , ......................................... Building Inspector