Loading...
HomeMy WebLinkAbout0240 WHISTLEBERRY DRIVE ��d �h��tie�ber R ram...- - _ -� _........ .. ..._.._. ..-_� .__� �--....r._ _ m .��:De �• ..a ..... ., :ems..�.. .. _ _v4.. __._ _ _ f r o• TOWN OF BARNSTABLE Permit No. ---------. ------------- 1 »nv4 Building Inspector Cash � "YL 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 shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to A:rtIft lr Ferris Address r. Wiring Inspector Inspection date Plumbing Inspector r �,P r� 1 ~ Inspection date Gas Inspector Inspection date 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. _ ...................................................... .....................» Building Inspector 'Jan. 29. 2020 8: 31AM ALTERNATIVE WEATHERIZATION, INC No, 5182 • P. 1-' - ALTERNATIVE WEATHERIZATI.O.N• C • .u9 � o Date: ow - a coo rn Town of Barnstable 200 Main St Hyannis,MA 02601 ';> Av Re:Permit# -`��� >'� "° Village: G '': �/`s1,f ::5�: :•.\-yea. ;•f"^:^'::.,`,. e:�v '':Tb tion/wreath'sk��;atioR:�irork.at `.��''•N:.: / .� �:>?:•:.;;;...:,.'R.�: a insula .... 6 •.� �•: .. ........ ��:. •ix n completeC coW�ance with �•��� Re Timothy Cabral, President CSL-105454 i 58 DICKINSON STREET ( FALL RIVER,MA 02721 'I (508)S674240 I ALTERNATIVEWEATHERIZATION*GMAIL.COM p � t Town of Barnstable Building 'Post.This,Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Gard Must be Kept t vMAS& $ Posted Until Final Inspection Has Been Made.`.. `.' pny.m�* i63p. �0 Permit 1. N039.ok Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit No. B-19-4132 Applicant Name: ALTERNATIVE WEATHERIZATION INC. Approvals Date Issued: 12/13/2019 Current Use: Structure Permit Type: Building-Insulation- Residential Expiration Date: 06/13/2020 Foundation: Location: 240 WHISTLEBERRY DRIVE, MARSTONS MILLS Map/Lot: 062-030 Zoning District: RF Sheathing: Owner on Record: OLSEN, NEAL R&VIRGINIA F Contractor Name: ALTERNATIVE WEATHERIZATION Framing: 1 INC. Address: 74 HARDING ST 2 Contractor License: 175683 MEDFIELD, MA 02052 Chimney: Description: weatherization Est. Project Cost: $3,233.00 Permit Fee: $85.00 Insulation: Project Review Req: Fee Paid: $85.00 Final: Date: 12/13/2019 Plumbing/Gas kyi�•re Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. - Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work:, Rough: 1.Foundation or Footing 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 1 ji Application number 1. ..- � _. Date Issued......j.d1all.y...................................... s Building Inspectors Initials.... ...:...:................... Tp ��c.. mop . ......... r .Map/Parcel...... ..... .....J? ............. :. ........... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/S IDING/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION _ PROPERTY INFORMATION Address of Project: NUMBE ,S T VILLAGE Owner's Name: Phone NumberJw- y(y Email Address: f -• (is e4 0 Cd)?I�bs� 4At-- Cell Phone Number Project cost$ 3d 33 Check one Residential t/ Commercial` . OWNER'S AUTHORIZATION As owner of the above ll property I hereby authorize - 6C6 w to make application for a building permit in accordance with 78 MR Owner Signature: Date: TYPE OF WORK ❑` Siding ❑ Windows(no header change)#. 0 Insulation/Weatherization ❑ Doors (no header change)# Commercial Doors.require an-inspector.'s4eview ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name n I& ,htj T�"C_ r I /## � � t Home Improvement Contractors Registration(if applicable)# /7J f'O �f 3 (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Q,lh1"Vl a h-Ve U2 ,47�W`� Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN. A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER ............................................................. *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X , X 5 X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am--9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APP IC 'S SIGNATURE Signature All permit applications are subject to a building official's approval prior to issuance. i ANE Town of Barnstable a 13ARI'STABU, Building Department Services 900 6�` 0 Brian Florence,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, Neal Olsen , as Owner of the subject property hereby authorize / l�Pa/1C� �/Q_ �.0 �i Z T act on my behalf, in all matters relative to work authorized by this building permit application for: 240 Whistleberry Drive Marstons Mills (Address of Job) Signature of Owner Signature d Applicant Nei a �� Print Name Print Name Date The Commonwealth of Massachusetts Department of Industrial'Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual):ALTERNATIVE WEATHERIZATION, INC.' Address:2 LARK STREET City/State/Zip:FALL RIVER, MA 02721 Phone#:508-567-4240 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 6 employees(full and/or part-time).* 7. ❑New construction In 1 am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition IM I am a homeowner doing all work myself[No workers'comp.insurance required.]t Q4. 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 1 L❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs,or additions 5.Q I 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. 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:LIBERTY MUTUAL INSURANCE Policy#or Self-ins.Lic.#:XW058867158 Expiration Date:06/07/2020 Job Site Address:P c City/State/Zip: O���A�✓70/I� �(�S� Attach a copy of the workers'compensation policy de ation 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 under eq an of a pry that the information provided above is true andcorrect Signature: t Date: fb L7 Phone#:508-567-4240 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 &Other Contact Person: Phone#: ' DATE M/DDlYWI� '4C' ' CERTIFICATE OF LIABILITY INSURANCE 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 NAME: Anthony F.Cordeiro Insurance Agency PHON o 508-677-0407 A/c No): 508-677-0409 171 Pleasant Street E-MAIL Fall River,MA 02721 ADDRESS: HSouza@Cordeiroinsurance.com INSURERS AFFORDING COVERAGE NAIC# INSURERA: Liberty Mutual INSURED INSURER B: Ohio Security Alternative Weatherization INSURER C: Ohio Casualty 2 Lark St INSURER D: Fall River,MA 02721 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY 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. VTR TYPE OF INSURANCE 1 D POLICY NUMBER MM DD/YYYY MM/DD EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE a OCCUR PREMISES Ea occurrence $ 300,000 MED EXP An one person) $ 15,000 A Y Y BKS58867158 06/07/19 06/07/20 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY 0 PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ ED SINGLE LIMIT AUTOMOBILE LIABILITY COMBIN $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ B OWNED AUTOS ONLY X SCHEDULED Y BAS58867158 06/07/19 06/07/20 BODILY INJURY(Per accident) $ AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident S X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS LIAB CLAIMS-MADE Y Y US058867158 06/07/19 06/07/20 AGGREGATE $ 1,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE n E.L.EACH ACCIDENT $ 600,000 C OFFICER/MEMBER EXCLUDED? NIA XWO58867158 06/07/19 06/07/20 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Action Inc and NGRID,USA,its direct and indirect parents,subsidiaries and affiliatesshall be named as Additional Insured on commercial General Liability and Automobile Liability polcies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN NGRID USA ACCORDANCE WITH THE POLICY PROVISIONS. 40 Sylvan Road Waltham,MA 02461 AUTHORIZED REPRESENT / ©19 -2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD i • r _ l +- CommonWealth'of Massachusetts Division of Professional.Licensure Board of Building Re uI tions and Standards Cons r ' tvisor CS-105454 ices:05/08/2021 TIMOTHY CA R L. 68 DICKINS(*'STRE FALL'RIVER 027`21 ' 4 Commissioner Office of Consumer Affairs,and Business Regulation 1000 Washington Street- Suite 710 Boston, M ssachusetts 02118 Home Improveme{ ontractor Registration Type: Corporation m R Registration: 175683 ALTERNATIVE WEATHERIZATION, INC. r Expiration: 05/28/2021 2 LARK ST w FALL RIVER,MA 02721 p a Fr ti Update Address and Return Card. SCA 1 4 20M•05M7 ✓X r�nr��zci�tcal� � llJdar <dCllJ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYP�E:�Coraoratlon before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation t;75==788�=��3:._._._ 05/28/2021 1000 Washington Stre -suite 710 r�� ALTERNATIVE WEAjIHERIZAT ON,INC. PIDeton,MA 02118 TIMOTHY CABRAi 2 LARK ST FALL RIVER,MA 02721 v Undersecretary of vdUdWithoAsignature r Town of Barnstable Permit: Regulatory Services Date: I C� FIKE rq Richard V. Scali,Interim Director Fee: Building Division RAMMBLE. ` Tom Perry, Building Commissioner MAS& v� 039• s�0� 200 Main Street, Hyannis,MA 02601 v Argo www.town.barnstable.ma.us Office: 508-862-4038 fFax: 508=790',230�y TOWN OF BARNSTABLE SOLID FUEL STOVE PERMIT �° 91-1,41 Owner: Neal R. Olsen Phone: 508-359-2103 Install at:~240 -Whistleberry.Drive I _ Village: Marstons Mills Map/Parcel: Date: 11/15/2 018 Stove A Ne /Used B. Type: adi V /Circulating C. Manufacturer: Hearthstone Lab. No. D. ModelNo.: Craftsbury '8391 Chimney A. Ne Existin (If existing,please note date of last cleaning) 11/15/2 018 B. Flue Size C rev 0 C. Are other appliances attached to o Flue? (fib D. Pre-fab Type and Manufacturer N14 E. Masonry: ine nlined Hearth 'rr � A. Materials: 7�g B. Sub Floor Construction: Installer Name: Sandwich Chimney Sweep Address: PO Box 90 Sandwich MA Phone: 508-888-5114 Location of Installation: 240 Whistleberry Drive Marstons Mills H.I.0 Registration# / 3-11-Q0 Construction Supervisor# e-5 f4 OR check_Homeowner Installing, no license re uired LICENSED INSTALLERS SIGNATURE: APPLICANTS SIGNATU 1 14'-A�. APPROVED BY: ' Please make checks payable to the Town o Barnstable *This constitutes an official stove permit after inspection,photographed, and approved by the Building Inspector Q:forms:stove Rev 11/4/13 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IF 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ( ( Please Print Legibly Name (Bus ess/Organization/Individual):��G V k,C O ke y\. Address• �,0 L"A ,\.st�e brr City/State/ ' : V�/1 "OW S �k t I Is VL R Phone#: SV? ` YdU' 3 Ste? Are you a-n employer?Check the approp1riate box: Type of project(required): 1.❑ I am a employer with 4� " I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ 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 workingfor mein an capacity. employees and have workers' y p t3'• 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 11.❑Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no . employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins,Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th pa' s a d penal ' !f eerj_ury that the information provided above is true and correct. Si ature: UU� C/�/`"- Date: / Phone Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i 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 permittlicense 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 information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-72774900 ext 446 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www,mass.gov/dia ACC>RV® CERTIFICATE OF LIABILITY INSURANCE DATE CERTIFICATE 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 have ADDITIONAL INSURED provisions or be endorsed. It 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 NONE; Erica H.O'Connor HART INSURANCE AGENCY,INC. PHONE 508-759 7326 x205 FAX 508-759-7366 243 MAIN STREET ac No: PO BOX 700 aDDRL g; eoconnor@hartinsuranceagency.com BUZZARDS BAY,MA 025320700 INSURERSI AFFORDING COVERAGE NAIC# _ INSURER A: EVANSTON INSURANCE CO 35378 INSURED- Sandwich Chimney Sweep INSURER B: ATLANTIC CHARTER INSURANCE COMPANY 44326 PO Box 90 Sandwich,MA 02563 INSURER C INSURER D: _ INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT70 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE (ADDS BR POLICY NUMBER POLICY EYF POLI pV EXP i LIMITS T A 1 COMMERCIAL GENERAL LIABILITY ! t 13ET6635 10/09/2018 10/09/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED CLAIMS-MADE �OCCUR I , i P SES occurrencel $ 50,000 i I MED EXP(Any one person) $ 1,000 I PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000 POLICY C jERo- ❑LOG j i PRODUCTS-COMP/OP ADD $ .OTHER: Ij I $ AUTOMOBILE LIABILITY I I EOMaBIN celdeD SINGLE LIMIT $ ANY AUTO I ; BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS I BODILY INJURY(Per accident) $ HIRED NON-OWNED :f PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY P r accId Is UMBRELLA LIAR OCCUR ! EACH OCCURRENCE Is EXCESS LIAR CLAIMS•MADE i AGGREGATE is DED I I RETENTION I is B WORKERS COMPENSATION I WCV01153104 05/13/2018 05/13/2019 PTR OTH• I AND EMPLOYERS'LIABILITY ANY PROPRIETORJPARTNERfEXECUTIVE 7N N/A( E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) ( E,L.DISEASE-EA EMPLOYEE $ 500,000 � If yyees describe under DESGtRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ _ 500,000 I i DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) CERTIFICATE HOLDER CANCELLATION Fax#:(508)896-4517 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF BREWSTER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. 2198 Main Street Brewster,MA 02631-1898 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD i v6 w+w.ww�w +cfro�uucua us ruuuV anicty .. Board o;Building Regulations and Standards < j• .7A� License:CSFA-OM57 Construction Supervisor 1 & 2 OfflceofConsumorAffairs&Bunn.asRegulation Family ' „` HOME IMPR EMIT CONTRACTOR Y TYCarooration KEITH A CLIFF . ExpIretton PO BOX 80 .e 031112020 SANDWICH MA 02583 SANDWICH CH1MNEY,S P"INC. KEITH A.CLIFF �qZrC.rGrie?`- Expiration: 28 EMERALD WAY Commissioner 02/27/2019 FORESTDAL.E,MA 02644 Undersecretary s ,; a r<<e •��e e u C4 yam_ CL _ SHEET I tfk WO*EAS z ti t m '"� ` "` t3StT $TN>r dt.1.Lf1IVitiC LiClrN3E r N F- 3 lS�r rrt••r� ,�V't `V a E� KEITH A�CLIFF drawAY ..�x-s, *+ �• ? �� e `J -a N � _ 28 EM f� ` 'FCftIE 1 lA.a`,'IW1 O ti44 iS330 i 0 construction Supervisor 1 &2 Family '-"-`" -------- Restricted to: Registration valid for Individual use only before the expiration date. B found return to: Office of Consumer Affairs and Business ReWation 10 Park Plaza-Suite S1T0 Boston,MA 02116 i Failure to possess a current edition of the Massachusetts Not • `ithout signakfre State Building Code Is cause for revocation of this license. DPS Licensing information visit WWW.MASS.GOV/DPS CONMOL# J 8 3 7 9 5 9 IMPOMANT yao�4f: o^.4 I : yt' VZ2 10 01. � Ra i�s tf your lsetskt,dame�dor g. 91' _ � Fit 11 Reds to be d�Y Isfiaccu►ate;or " E•z N nsf iuctions to corrected. o��b sf6e at rtfass,gov/dpl for m $$� motion and any otherP+oP� i 9 Your Renewal r 3 2 r g s L 0 Rrks license is sspondence. c e g$ iF a_ a 3 ^ ^g O rift li ens, is suur Massachusetts General Laws and 11 1 a!I I - 1111 g tD tsstgned to an a privilege,and cannot be lent or qs Un;; �'€ e g O tense on y�pin or posted�ry under penalty of law.Keep this 2' �� x is e�` 3 a e t� fill, M 49ulatlons. required by law and/or si e k s; $• $ s g ^ 1�1 gill �g��� N I The Commonwealth of Massachusetts Department of Industrial Accidents a 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 Leeibly Name(Business/Orgunization/Individual): SANDWICH CHIMNEY SWEEP, INC./KEITH CLIFF Address: POST OFFICE BOX 90 City/State/Zip: SANDWICH, MA 02563-0090 Phone#: (508.) 888-5114 Are you an employer?Check the appropriate box: Type of project(required): 1.54 Lam a cmpluycrwith j_wnployces(full and/or pon-tune).' 7. []New construction 2.❑1 am a.sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.O I am a homeowner doing all work myself.(No workers'comp.insurance.required.)r 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all conuactors either have workers'compensation insurance or are sole I LM Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub•commctors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t / 6.❑We are a corporation and its officers have exercised their right of ex ration 14.®OtlteCy �/11X7/]Y rpo g 1 per MGL c. `` 152,§1(4),and we have no employees.(No workers'comp.insurance required.). n , *Any applicant that checks box gl must also rill 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. ,Conrractors 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 subcontractors 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 inforJnation. Insurance Company Name: ATLANTIC CHARTER INSURANCE CO. Policy#or Self-ins.Lic.#. WCV01153104 Expiration Date:1 05/13/2019 Job Site Address: VOA15rHe6ffu lib City/State/Zip: MIA 63000 a Attach copy of the workers'coinpensat on policy declaration page(showing the policy number and expiratio 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 cert'I art a ains andpenaides of pet fury that the in/orntation provided above Is true and correct. r Signature. Date: Phone#: (508) 888- 1 JtV 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): i.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector G.Other Contact Person: Phone#: Assessor's map and lot number "". .................................. �o f THE Toy �i�'�� ' Sewage 'Permit number .................... ................................... Z EAHB9TADLE, i House number ............:., rasa 00o�i639, ♦� TOWN OF BARNSTABLE 1.. C BUILDING INSPECTOR APPLICATIONFOR PERMIT TO ,e X/ -e fe...............:...................................................... ..................................................... I TYPE OF CONSTRUCTION .............................................. ................................y/......:..................................... ....... ...........................19........ .v. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following 'information: i�Jf<.......... ...../..y`� . Location ................................................... . . ProposedUse ............. ;1:21/sc/4.............................................................................................................................. d ZoningDistrict ......../................................................................Fire District .............................................. ............................... Name of Owner U��/ �Ucf�? �S ���f�� ......,.................. ...... .......... ....................Address ................ .........�:............>..................................... Name of Builder' .....���`£N..........<J..�iU ..............Address i� .... .......... ................................... ......................... 5�1 Nameof Architect ..................................................................Address .................................................................................... Number of Rooms Foundation .....�� /..1..................... / Exterior ��/a/J ,�JG/7/� //f!T�/��1 .P..Roofing .............. 5�] . ? T,........................................ ..............`.... ........................ ............ Floors / ij?� ..... ?..... .............Interior ........... ........7�c ..... .... Heating /� fit Plumbing ..........ram: �>NS /S".. L fic. /' Fireplace /�/�.................................... .......................Approximate Cost ............ �. ?. -X--��.�.......................... ..................... Definitive Plan Approved by Planning Board -----------_------_-----------19______. Area ........................................... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH 0 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. 677 Name . :% � % �:...�............................................. FERRIS, ARTHUR A=62-30 l Stor No 2.4.Q.�Q. Permit for X............... S.i.mgJ.e...FamlY.:..Dwellin.�............... Location Ai.ot...#2.6......2.4.Q...Wh stleberry Dr. ................. ......................... Owner".Arthur Ferris Type of Construction .•,Frame Plot ............................ Lot` ................................ Permit Granted ..:.:. 'lc3y....l$:.................19 82 Date of Inspection .....................................19 Date Completed .............................. .......19 map and lot number ................. m� 7F -��� / SEPTIC SNyS8E�� ��K�SV v�u:-Z SINE Sewage Permknum6er ..����--..�.1--------.� ALLED IN � H�uue nun��, *r���%�- ' ' ��ovry v""LE °~ � ________.. ______----'` `'. ENVIRONMENTALt639- TOWN OF BARNS ~ ~' � -. BUILDING Ifl'S.PECTOR 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: / ZoningDistrict -...-.-...........-......-..-.-.Rne District ............................................................................ ^ Name of"A"ner � x�*�� Address | -..,~.^^--.~.~, -.~...~^--....----. ----...~~^.^^~~.---------------- / (tName "fj"//6er. -'~ =--'. ° �----'A66res '=~�=�`� _+� Nome of Architect --.. ����^�~�.����. w'--A66nss ............../.................................................. -____. Number of Room, .............�....................................................Foundation ...... .................................. Exterior Roofing ---- ........................................... Floors ............ ..... ........ ---- ...................... �~- | Heating -.--- -- ~ .*� �� --'F1um6nQ ---..-±2- _.~.^/. ��� R,ep|ooe ---- ^�x��*�'. -��.,���� ----App,ouimoheCox ---- ~« DafnhivePlan Approved by Planning Board l�----. A,eo -' ^�. ........... Diagram of Lot and Building with Dimensions Fee .............................. SUBJECT TO APPROVAL OF BOARD OF HEALTH ' \ v/^ | \ � | » | \ ' 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 Name .�A... ........... ......z ` -~ FERRIb, ARTHUR 13-2 Story 0 ... Permit for .................................... .Mily Dwelling.............. ........................... Location ...UQt...ff.2.6..... Dr'. ................. Q.AS Mills. ........................................... Owner .............................. Type of Construction ..Fr.aD.e........................... ................................................................................. Plot ............................ Lot ................................ Permit Granted ....N4Y. 19 82 ..a,.................. Date of Inspection ....................................19 -7 Date Completed F...... . .............19 A-4 . s f,4 V. V✓AY PJ i i 1 ION C o �t .COr o26 op ri /0.7 0 0 CERTIFIED PLOT PLAN IN A:jAR5 To/ 1%l/G.L J 14 A SS. dE//-/,F .car .26 0^/ PLs'N BiK .3y9 P4 .sG_ IRA R.THACHER, JR. REG.. LAND SURVEYOR SO. YARMOUTH;MASS. DATE s-�7- 8.z.- SCALE I IF of Miss DRAWN BY //LT - SHEET %." OF p='r�K %- ? 1 CERTIFY THAT THE EX/ST/N,� ado TH y • FauvoA7'iani-SHOWN ON THIS PLAN . . 3214 O F GISTE- � CONFORMS TO THE ZONING BY- LAWS p �9No 5Ug*4 OF THE TOWN OF REG.-LAND SURVEYOR F /V//C C o L o.v iA C G'.�?�ti 6FI2,1r Co 10 ly /o/ 103 X PAN 5—/p.V 2- /O Fr pig — — q /o Y.,_ E �) 1 log / /o S 9 3� 4 To.i 51Q TDi� �'Y�R�.T do..o /'Z•7 - - / - 9 0 nx y _ — 97 "/ yvH/s r.CEB�2,rZ y .20.o•� • I CX/STi�t/� S�oT ELEYAT"/oNs 910. 9 CERTIFIED PLOT PLAN IN cLEv�9Ti0,vs BASED oti /955�/y/�� /�lr4/ZS7'di�s /n/LLS .��,�5 Di9Tc.ry� -. ToP //yDRrO�r /oo , av 'c2=/�ve� .L a __2 d ?ry�7 S6 _ t SST/,,.y P,eoPos t o 4WIVPf-s To IRA R.THACHER, JR. .Q�11,9iv cssF�r/iOG�,/ T.S/�' so/!�E REG. LAND SURVEYOR SO. YARMOUTH , MASS. DATE -f/2-82- SCALE I"=VO' DRAWN BY /27- SHEET /-' OF 2 of M4sq I CERTIFY THAT THE /WoPosro 94-/40,1�y SHOWN ON THIS PLAN � IRA s CONFORMS TO THE ZONING BY- LAWS .: •=! ° T y OF THE TOWN OF 8i4 L� J•lr',�=r� � No. 3214 � No.c.• a.. �`/STel?L REG. LAND SURVEYOR SOIL TEST INVERT ELEVATIONS NOTESS DATE OF SOIL TEST L 8Z INVERT AT BUILDING 4. 9 FT. ALL WORKMANSHIP AND MATERIALS WITNESSED BY e-6' INLET SEPTIC TANK 1,04- ? FT. SHALL CONFORM TO D.E.Q.E. TITLE 5 PERCOLATION RATE t MIN./INCH OUTLET SEPTIC TANK ,lam FT. AND THE TOWN OF 9_,A9P-1'srglycr- RULES o AND REGULATIONS FOR SUBSURFACE OBSERVATION HOLE I OBSERVATION HOLE 2 INLET ' DISTRIBUTION BOX a o FT. DISPOSAL OF SANITARY SEWAGE ELE�ATION =/07. ELEVATION= /o� OUTLET DISTRIBUTION BOX /�3 6 FT -0 INLET LEACHING PIT 4,23. `f FT. wooncaor, wooDcoi9� BOTTOM LEACHING PIT' 97. 4_ FT 5w3so/ s Qso DESIGN CALCULATIONS ' CGAy F/�/ES CGgy F/n/ES -48' -48 NUMBER *OF BEDROOMS .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . GARBAGE DISPOSAL UNIT... CLE9/J MEA- G"L6.S�/�� /yl�o TOTAL ESTIMATED FLOW ( GAL./BR./DAY x 4 ys AN BR.)... 44 GAL./DAY I' 44 eo, .2E SD co q�E S•,9.�/p REQUIFLED SEPTIC TANK CAPACITY.... . . . . . .. . . ° GAL. ACTUAL SIZE* OF SEPTIC TANK TO BE INSTALLED... . �ZS GAL. LEACHING AREA REQUIREMENTS Fc' 97• G —/ 3 ZFc - 93 SIDE WALL AREA Z• ' GAL./S.F. BOTTOM AREA AO GAL./S.F. �O:_:.W/9TElZ --IVQ 1Ni9TF2 - LEACHING ' CAPACITY ( BOTTOM tS�DEWALL ).. .... . . . .. . /099.6 GAL. RESERVE LEACHING CAPACITY. . . lag 9, G GAL. ZO Fr m/�✓ ;: TOP OF FOUND. ELEV.= 1078 /4 FT• ^)-A/ CONCRETE 4 SCH. 40 CLEAN SAND COVERS PVC PIPE ' MIN, PITCH CONCRETE I 1/8 PER. FT. • 2 2% MIN. PITCH � OF s o ,t 1 � MAX. y 3 Z I �� u r RICHARO FLOW LINE9 2 LAYER OF I/8- I/2 " JAMES �+ WASHED. STONE " O'HEARN `" No.694 4" CAST IRON �09 PIPE MIN.. PITCH w WASHED STONE 1/4 PER FT. DIST. o Lk F_ ° PRECAST LEACHING BOX 4:0 �D w�W o BASIN OR EQUIV. —� Q l+-o o ,y � �i• o p D . Ov �D W v �T 26 w.S�/STLFf3F_.e�Y /25-0 GAL 6 Fr 23,9otis7-Ar3�-� _MASS, SEPTIC 4 )rr TANK /d FT D,,9 J R. J. 0 HEARN, INC., RLS, RS 1348 ROUTE 134 PROFILE OF GROUND WATER TABLE EAST DENNIS, MASS. SEWAGE DISPOSAL SYSTEM JOB NO. ICLIENT /,e7 NOT TO SCALE DATE 6/z1, i SHEET Z OF `- i•