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HomeMy WebLinkAbout0460 WHISTLEBERRY DRIVE ►� Town of Barnstable Building Post This Card So That it is VisibWFrom the Street,-Approved Plans Must be Retained on Job and this Card Must be Kept snMsrwei.s. MARS Posted Until Final Inspection Has Been Made. Permit ' raa+• Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit No. B-20-2188 Applicant Name:` Robert Rostocka Approvals Date Issued: 08/25/2020 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 02/25/2021 Foundation: Location: 460 WHISTLEBERRY DRIVE, MARSTONS MILLS Map/Lot: 062-053 Zoning District: RF Sheathing: Owner on Record: O'SHEA,TERENCE A& LAURIE T Contractor Name: Framing: 1 _ Address: 186 BENNETT ROAD Contractor License: 2 HAMPDEN, MA 01036 Est. Project Cost: $ 1,102.00 Chimney: Description: Insulation&Air Sealing Permit F e: $85.00 Insulation: Fee Paid:) $85.00 Project Review Req: Date: 8/25/2020 Final: Plumbing/Gas Rough Plumbing: \Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced withih.ssix months after�ssuance. All work authorized by this permit shall conform to the approved application and the(approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. I Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: Service: 1.Foundation or Footing 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lin'in'g is iFssta'lled 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: S.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: f The Town of Barnstable Department of Public Works 3 82 Falmouth� Road,Hyannis,MA 02601 B A E M1VJ MSTA 1�1 1I1llL N www.town.barnstable.ma.us 1639-204 Daniel W. Santos,P.E. Office: 508.790.6400 Director Fax: 508.790.6343 October 27,2016 Frederick J Kozak&Teresa Yaegel 460 Whistleberry Drive =_ o Marston Mills,MA 02648 ¢ SUBJECT:Numbering of Buildings :vCu c Map No. 062 Parcel No. 053 � cn Dear Property Owner, Notice is hereby given in accordance with the Code of the Town of Barnstable, Chapter rn 51,Numbering of Buildings, adopted August 18, 1994. Public convenience and necessity requires the assignment of number 460 for your property located on Whistleber y Drive, Marston.Mills. This number should be affixed to your building so that it is visible form the street as outlined in exhibit "E", Town of Barnstable Rules and Regulations for Numbering of Buildings. To date, the past address for the Map No. 062 Parcel No. 053 was 19 Waters Edge, Marston Mills.,Upon review from Centerville, Osteiville, and Martstons Mills (COMM) Fire Department during a recent fire inspection, the past address did not meet proper emergency response practices. The property has a recorded access easement (Book 349 Page 58) through Map No. 061 Parcel No. 055, which has frontage along Whistlebeny Drive. The Whistlebery address reflects legal access through the property for emergency response to Map No. 062 Parcel No. 053. COMM Fire Department has agreed with this change of address. Please contact the Engineering Division of the Department of Public Works at(508) 790- 6400 and be prepared to provide all telephone numbers at this location so that your E-911 account records can be confirmed when the correct number is posted. Sincerely, Rogerr.Parsons,P.E. Town Engineer Assessor's offioe (1st floor): // r �Di?NE D Assessor's map and lot number ................................. 3. Board of Health (3rd floor): O� Sewa a Per'mit number ..�.s.g f, 1i BAUSTADLE, i Engineering Department (3rd floor): 9 NAM o• \e�' Housenumber .........................................ove........................ �c�aya' APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only 2 TOWN OF BARNSTABLE sG�c BUILDING INSPECTOR Q�.....0........I b.� l.� �_.. APPLICATION FOR PERMIT TO ..... ........ ..... .................... ... .....;:...................................... TYPEOF CONSTRUCTION ...........................................................................................:..........:.............................. ...........1977 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby lapplies for a,permit according to the following information: 1 Location ....�.. . ........WT5................. .. ..1..MS..i u..�.5..... ,�).1 ..... • Proposed Use ................................................... Zoning District .... ..�.. '.........................................!.........Fire District ........ ... ......... l (� y� y� II .... .............................. Name of Owner l r 'f'.. 6�..OA..6.(."rl�Address ...J ..... r.�i-S..�... ...........:... QQ Nameof Builder ....................................................................Address ................................................................:.....:.:.......\. Name of Architect Address .................................................................. Numberof Rooms ..................................................................Foundation ..............................................:.. ............................. Exterior ..................................... .................:.................�.........Roofing ......................................................................�!'�......... r Floors ......................................................................................Interior .......... .......... ............... .................................... Heating Plumbirt'g ........ .................... Fireplace ......................Approximate Cost ..tP...v �� CJ Definitive Plan Approved by Planning Board __________ _____________________19_--_____ . Area . ..� :..-s/*............ Diagram of Lot and Building with Dimensions Fee ......................... SUBJECT TO APPROVAL OF BOARD OF HEALTH 21, 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 .... �—�..�1..�.C;�.l.... ..... Construction Supervisor's License ....................:�.............. BINFORD, GREGG & DEBORAH A=062-053 S2 30822 Build Shed No Permit for .................................... Accessory to Dwelling .......................................................................... 19 Waters Edge Location ................................................................ 'Marstons Mills .............................................................................. Gregg & Deborah Bindord -Owner .................................................................. Type of Construction ........Fr.aM.e..................... ..................... ................................ Plot ..................I........... Lot ................................ Granted ........June... Permit Gran' .......... .......19 87 Date of Inspection ....................................19 Date Completed ......................................19 0 Assessor's map and lot number �`� �� „............ .. ................... CF THE TO Sewage Permit number .................... ................................... d Z BAEBSTABLE, S House number ...............�.f/..��...................................., yO MAB6 pe,t639. `00 G�� �FD MAR a' TOWN OF BARNSTABLE � sr BUILDING INSPECTOR APPLICATION FOR PERMIT TO ............... ��'.`a'�s�,�2�, ry 1.,��:� ,'' ?";s,.._ ............... �:� ...J��.�.t.�7 TYPE OF CONSTRUCTION ................. ? ::... :........a !'.'.'•r .................................................................... .................... w:.:...: ::..:.........19......... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ............:.... '.�T... .........GIJH/SiG �J.<—�,.� jv... f?..�/:�dl.�%di5�0>J �'L'>,/���STZ�i✓�.YLI/lLs ProposedUse ........... �/�L-7fC4..................................... ................. ...................................................................................:.............. ......Fire District .............�.........�.Zoning District ...... ... .................:............................... Name of Owner .�74?.... �NU°e ...........Address ... ........... ..................................... ..........:vim......... Name of Builder ....���L'/'/9rcZ(7... A./ .!/....................Address ... � ... Nameof Architect ..... /j'/. ............................ ...............Address ......................................:.............................................. Number of Rooms ........Foundation. �0A"ClZd7-, .......................................................... .............................................................................. Exierior ...................... .. ...............................Roofin .............. .... , ........ ..................................................... Floors 724 ;..Ce:?RIoL"T.�.... .9A..............`.......Interior ...........Sh!LZ?-®ZOCOtC....................................... ... Heating �LECTs ... ..... Do�..................Plumbing .......//' .� ?7'/�5.......................................... Fireplace .......Approximate. Cost ............r�.?•t..!�................. e... Definitive Plan Approved by Planning Board -----------_______-----------19________. Area ......... Diagram of Lot and Building with Dimensions Fee 0 .. SUBJECT TO APPROVAL OF BOARD OF HEALTH oa4A A-t,W R"a Q J N o n1 o`� 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 ............ G/ ...1� �lZGC............... Construction Supervisor's License ..... 0 yili...... /2 Q Qum BINFORD, GREGG A=62-53 No -Permit foi* ....... ........... .........Sin le...Family Dw ........ .. V.... ...................... �0\ Location ......ipt..44,.....Wate-r-a-Edge..'Road.. ................ .......................... Owner ........!aKP_gg....Biaord.......................... Type of Construction Frame............................... ........... .................................................... . Plot ............................ Lot ................................ Permit Granted ..Marsh .19 85 Date of Inspection ....................................19 Date Completed ......................................19 1,4 ' Assessor's offioe (1st floor): // 3 o A® C � 0 �. . Bpi?NEtO Assessor's map-and lot number ..............................:......... Board of Health Ord floor): K ��I , 9RT 6C SYSTEM � Sewage Permit number .............. ......... + ii �UTALLED IN CO Engineering Department (3rd floor): WITH TITLE i639• �00� House number ................................?......o`.u-e......................... ENVIRONMENTAL CO a APPLICATIONS PROCESSED 8:30-9:30 A.M. and; 1:00 2:00 P.M: only TOWN REGULATIO' S o`er w TOWN OF BARNSTABLE 2G BUILDING INSPECTOR APPLICATION FOR PERMIT TO .-........!.�.x.. .... .............................................. TYPEOF!CONSTRUCTION ..................................................................................................................................... nt ,.,S............t9.V TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permitt�according to the following information: Location ....,..q. W S ��W......u..� S 1 f 1 1 I ProposedUse ......................................................................................................... .... ............................................................ Zoning District .... . .x:.�°°. Fire District ....,... / /' /...... .......... .......J............................... �r -..fie. a QA..6.�."r� d' dress ...I ..... l S..�-. .. Name of Owner ... . .. � ............. Nameof Builder ....................................................................Address ..................•.................................................................. Nameof Architect ..............................'....................................Address .................................................................................... Numberof Rooms ..................................................................Foundation .............................................................................. Exterior ....................................................................................Roofing .................................................................................... Floors ......................................................................................Interior . ..................................................................... Heating ..............*...... ..:..—..,................................................Plumbing ..:........f ........................... ...r...................... . ........ Fireplace ....................I..........................Approximate Co, . Definitive Plan Approved by Planning Board --------------------------------19-------- . Area ...�. .... ............. Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH A • ldx� � �5� 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 .................................... ppp;_-INFORD, GREGG & DEBORAH 30822 ....,Build Shed No ................. Permit for ............................ Accessory Dwelling .......................................................................... Location 19 Waters Edge ................................................................ Marstons Mills F. . ............................................................................... Owner Gregg & Deborah Binford .................................................................. Type of Construction .................Frame......................... .................... ............ ............................................ Plot ........... ........... Lot ........................... .......... Permit Granted .......4une....5...,................19 87 ........ Date of Inspection .................... ... ......—19 Al?, Date Completed ........ .........19 o. Ell TOWN OF BARNSTABLE Permit No. ----------—----------------- 16K Building Inspector cash ---------—_----7�� 7 /Yl OCCUPANCY PERMIT Bond Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date Board of Health 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 AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ....................................................... 19........... .................................................................................................................. Building Inspector - slf:TERS EDGE 50 ' L. 4 Zo s. d 1-6' ' .x6 . Q -Pit o i 4N 8G.SG. Stone ji s /2 , -;tone = 26'7 .F. = 54'� 100% i x1. ao- L ot 43, n J •?1-B a- % 1500 ' h D Lot j C PAOFiLu 46 L _�t 44 ��� `_ G/ NO SCALE Existing, ;s p, '�oiundation � j " ,,,lev. 28.9 - za;a N a ' rn I N 1500 I " G:S.P. 2® I Ir . - r- 1 20. P zo7.0a ` 3 0 �° ry '.Fnd.: Y•T, `T Lot 5: FIB N .SG��LE lti 40' Date 2/9/$5 49 ..arbor T L R Q, 'L 11. 1�ARS TRNI� .i y LL S,� t �; . • ' for Gregg Sihfcord 3ein- lot 44 as :s otm on a ­lan o ;rnis-tleb err 3r I rd re corgi?ed on. p an boot. 3'1F9 p�;` 5 ; Barn stable iZe;ist�,zr o.r deeds,' r'lev,n ti.,,ns s-'-,aw n !are.-on ,-..ri .assumed datum. e1%, C"' n---------- _-- -� —--------- 1------.;-_ --- -.- 7te . ,4g'eht.. P�.rn-t �, „o of 3Iealth erc. ,, . `: 2 min. , er 1 r The rc),Imdation shown on this. is. �lo.gateid 1 on the gro:und 'as; shown thex6on and ;lia:t; 'gyp con.`'or;;is to the jzoning and sbuildinL 1aws .laf` the- ` Tor Toi,m of Barn­�t.a•ble vr-h-e-n cc tructer', ai-id--�te t1 i .. z3.g restrictions on re.cord.. j Date : 3/1/85. ! ' � '' \i "At df �. p YJILLIAMH. v, o FARDIE : Cn No 8m ..._ . � `ti"rvti��=y.��:�,r•. .1.-f-:.. FSSl0�lk1.�6 Assessor's map and lot number ��.......... TNET .......................... ... .. OF Or, ®� -3 o Sewage Permit number ...... ............. SEPTIC e� SYSTE wd�.1u� Z pB'ABB A3BTaO DLE�, House number p �� ��.LED IN COAP L+,�............. 1639- WITH TITLE s 0MAI a. TOWN OF BAR NS'7T � ''4 `' BUILDING INSPECTOR APPLICATION FOR PERMIT TO ............... . TYPE OF CONSTRUCTION ..........:.......4�.�.. ... ..................................................................... ................ ............IqZ;r r TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit uJ/faccorTenSding to the following information: Location �:.�T... �f ll�.!STG7 ..!�S.M/zzj ProposedUse ��.���;2t-7�(� ................................................................................................................................. Zoning District ....:.k4.e ... 6............................................Fire District ............1f .................................................. Name of Owner ........ .... �N �...........Address ... .....4 �'.....�T.... Name of Builder ...121G/� i2d�....�7 .1� ....................Address ...F�?::�...zel.��.f}/ llt',S.1W.l- Nameof Architect ...... ../�m.E............................................Address .......................................................................... Number of Rooms 8.............................................Foundation ©/1/G.L�Tr "CcJ �O� .................... ........................................... . .... .. ........ . Exterior L�4!�®�d.9O/ ...............................Roofing ��.1�f � ................................... ....... g ...........�i Floors ......�`4.�j...� R!� '..,....l��9t�G.....................Interior .......... STOC/� ........................................ Heating ......... LEC: !S� ,. .�© ..................Plumbing ......�/ai7 �?f/S Fireplace ..........lr[1©0p SAD✓ / T..f�........Approximate. Cost ............`/�D�.4..................................... Definitive Plan Approved by Planning Board -----------_-------------------19________. Area ....................................... Diagram of Lot and Building with Dimensions Fee .........C �1 4......................... SUBJECT TO APPROVAL OF' BOARD OF HEALTH o M - 60 - v 9'f ,,1o7 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. .��••� DD SAL . Name ............... ........ ....F�.,O..�. ..........................:. t� Construction Supervisor's License ......A&P.7..�....... BINFORD, GRBGG No ..27596.... Permit for A-, Story ........... .................................... Single Fami1X Dwelling ...................... Location ....Lot 14r.....Waters..Ede..Road.... Marstons Mills ........................................................................ ...... Owner ....Gregg,Binf Ord................................. Type of Construction ..Frame............................. .......... ............. ........ ......................................................... Plot ............................ Lot ................................ .Permit Granted .... March 12, 19 85 .................................... Date of Inspection .. ..............................19 Date. Completed .......... 19 R, Town of Barnstable *Permit#,�.260(p L Expires 6 months from issue date Regulatory Services Fee Thomas F.Geiler,Director Building Division ®� Perry,CBO, Building Commissioner V R �-PRESS P 00 Main Street,Hyannis,MA 02601 A� www.town.barnstable.ma.us Office: 508-8624MV 15 2006 Fax: 508-790-6230 EXPI2F.SsSt�►FrBi1'I�T APPLICATION - RESIDENTIAL ONLY �BPCTmrv�• TOW � Not Valid without Red X--Press Imprint p/parcel Number Z perry Address Residential Value of Work Miinnimmum fee of$25.00 for work under$6000.00 er's Name&Address `'�� 14Z_0 iid C 2 /Yl�d"S&J'e? -7l/S ntractor's Name- y�-�, r � �� `(� �' Telephone Number .�Q� • v me Improvement Contractor License#(if applicable) 'c��{�PPlicalrle) Workman's Compensation Insurance Check one: ❑ I am a sole proprietor E1,1arn the Homeowner have Worker's Compensation Insurance ance Company Name �1� } -^ rkman's Comp.Policy# /� _ ���"I l� #' y of Insurance Compliance Certificate must be on file. t Request(check box) p(J Re-roof(stripping old shingles) All construction debris will be taken to ��6S-P / Was J❑�Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Prop rty Owner must sign Property Owner Letter of Permission. py of the Home Improvement Contractors License is required. NATURE: =s:expmtrg se061306 i I i 19 ®®Ema�®e®®e"96 p KETTEL OOFING -�-i� AND SIDING -� SERVING SQUTHEASTERN MA AND THE ISLANDS YOF yao-SBor Y- re� KozlkK 7//7/06 0.4 CC s e d v X . grave kt �alakgq/' 74 WeA e-rtd 0 5 w0 - A' vck4e-J i c°PP$r ✓aI1- -for bofk dor'rn VLC ie7S Lollj m4rk T;l — 7190100 r� .. P.O. BOX 670 • SAGAMtORE BEACH, MA 02562 • TEL: 50B�BBB-3744 "LICENSED.AND INSURED The ommonwealth-ofMassachusetts w� C 1 I ,; Department of Industrial Accidents Office of Investigations i 600 Washington Street \ Rj Boston, MA 02111 "1 www.Mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):. Address:_ &1,90. ,AQX �O City/State/Zip: Off'?5 bf4� 4M6'/Phone#: 50 F- S-Iqy AR/You an employer? Check the appropriate box: Type of project(required): 1.4 I am a employer with 3 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the'sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling ship and have no employees ' These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its requiied.] officers have exercised their 10.ElElectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions . myself. [No workers' comp, c. 152, §1(4), and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other '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 their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �`ad�'V—( PS (/� �J��a� Policy#or Self-ins.Lic.#:_ �t 3 gp� r��` Expiration Date: O d Job Site Address:1_ vTl/i'�/ems City/State/Zip: IM Soo /we I/( , Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a . fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u e pains and penalties of perjury that the information provided above is true and correct Si ature: Date: Phone#: O 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 certificates).of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance, If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department.of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy.information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts l kepartmgnt of Indusixial Accidents office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-8.7' MASSAFE Fax.##617-727-774.9 Revised 5-26-OS wwwmass.gov/dia A 08-24-06 09:53am From-AIG +973 331 $599 T-414 P.001/002 F-545 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE lst-Murraymsurance Agency Inc. HOLDER.TER TM COVERAGE AFFORDED SY THE POLICIES EXTEND P.O.Box 38 BELOW Bo West Dennis,MA 02670 COM ANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED Justin G.Kettel P.O.Box 670 Sagamore Beach,MA 02562 MEN THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY sE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAID CLAIMS, CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE PATE POLICY EXPIRATION D TE A WORKERS COME TCO LIMITS AND EMPLOYERV LIABILrIY { + HE PROPRIETOR/ ARTNERSfFXeCUTIVE I OFFICERS ARE; UTORY LIMITS INCL O D= 4392107 08/01/2006 08/01/2007 STAT THER wstege AppUw to MA OPEMAJau Only. EACH ACCIDENT $100,00 DISEASE POLICY LIMIT $500,00 eAsE EAO FaAi�O E $100 000 DESCRIPTION OF OPERATIONSIVEHICLESISPECIAI ITEMS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEWED DEFORE THE ALEXA KELLY EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL'�a 20 PARADISE BLVD. QAYS WRITTEN NOTICE TO THE CEATIFICATE HOLDER NAMED TO THE LEFT,BUT CHATHAM,MA 02633 FAILURE=TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UABILITY OF ANY KIND UPON THG COMPANY,ITS AGENTS OR REPRESENTATNES. AUTHORIZED REPRESENTATIVE 69- 41 ' n t] 0 x > Board of Building Regula ons and Standards A D o One Ashburton Place - Room 1301 z z M Boston. Massachusetts 02108 ; o � � . � Home Improvement Contractor Registration D z t� 0 n N D D ? Registration: 140657 m N -0101 o Type: DBA z .D Expiration: 11/10/2007 a W o KETTELL ROOFING z A N JUSTIN KETTELL oN P®p�BepO®X� 5p69 napp �g .g in 10� o SP1�iAMORE, MP102561 D N Update Address and t'cBeAr®card.tOgar@6 reas®n for.change. 0 OPS-CAI A SOw-awos-PCOSOO Address F� Renewal Employment Lost Card w w J A f 08/.15/2006 TUE 14:05 FAX 508 564 5531 BOUCHIE iNSURANUE WjUUI/Uvt ACORD,M CERTIFICATE OF LIABILITY INSURANCE DATE 08114/20 6 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Robert E. Bouchie Jr. Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1352 Rt 28A ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box 400 Cataumet, MA 02534-0400 INSURERS AFFORDING COVERAGE NAIC# INSURED Kettel Roofing INSURERA: ESSEX INSURANCE CO 39020 5 Bob White Lane INSURER B: Safety Sandwich,MA 02563 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR D'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONTYP LIMBS A GENERAL LIABILITY 3CU9482 07/28/06 07/28/07 EACH OCCURRENCE $ 1.000,000 COMMERCIAL GENERAL LIABILITY DAMAG TO RENTED PREMISES(Ea omrencel $ 50,000 CLAIMS MADE OCCUR MED EXP oneperson) $ excluded PERSONAL&ADV INJURY S 1 000 000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 1000000 POLICY PRO LOC B AUTOMOBILE LIABILITY 3948402 8-12-06 8-12-07 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE S (Per accdent) GARAGE LIABILITY AUTO ONLY•EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S 'I AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE _ $ OCCUR CLAIMS MADE AGGREGATE $ _ a DEDUCTIBLE $ RETENTION $ $ I OTH WORKERS COMPENSATION AND WCSi J}( EMPLOYERS'LIABILITY ANY PROPRIaTOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ _T OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE S IFyyaess describe under SPECIALPROVISIONSbelow E.L DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Alexa Kelly DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 20 Paradise Road NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Chatham, MA 02633 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTA AUTHORIZED R W(V & ACORD 26(2001/08) 4ACORD RP (RATION 1988 a 0 x 0+ N Board of Building Regula ons and Standards o One Ashburton Place m Room 1301 Z Boston. Massachusetts 02108 Oak M D Howie Improvement Contractor Registration D z C� O [7 a z Registration: 140657 m N Type: DBA z D .... Expiration: 11/10/2007 D W o KETTELL ROOFING z Z X W JUSTIN KETTELL ° 0 N PO BOX 569 SAGAMORE, MA-02561 N r Update Address and return card.lOZarl<reason for change. ODPS.CA1 5OM-04/05.PQ698 Address Renewal Employment Lost Card m - � rD ra . W J A A